Healthcare Provider Details

I. General information

NPI: 1992281489
Provider Name (Legal Business Name): MADONNA IBRAHIM CPO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 FROST ST STE 320
SAN DIEGO CA
92123
US

IV. Provider business mailing address

7910 FROST ST STE 320
SAN DIEGO CA
92123-2791
US

V. Phone/Fax

Practice location:
  • Phone: 619-488-6196
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCPO04103
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCPO04103
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: