Healthcare Provider Details

I. General information

NPI: 1063451771
Provider Name (Legal Business Name): MAHMOUD ALI IBRAHIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7974 HAVEN AVE STE. 290
RANCHO CUCAMONGA CA
91730-3052
US

IV. Provider business mailing address

7974 HAVEN AVE STE. 290
RANCHO CUCAMONGA CA
91730-3052
US

V. Phone/Fax

Practice location:
  • Phone: 909-944-5553
  • Fax: 909-944-3339
Mailing address:
  • Phone: 909-944-5553
  • Fax: 909-944-3339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA42803
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberA42803
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: