Healthcare Provider Details

I. General information

NPI: 1407899610
Provider Name (Legal Business Name): IHSAN I JABBOUR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 GRANDVIEW AVE SUITE # 105
WATERBURY CT
06708-2517
US

IV. Provider business mailing address

171 GRANDVIEW AVE SUITE # 105
WATERBURY CT
06708-2517
US

V. Phone/Fax

Practice location:
  • Phone: 203-755-2214
  • Fax: 203-596-1133
Mailing address:
  • Phone: 203-755-2214
  • Fax: 203-596-1133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number026820
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number026820
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number026820
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number026820
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: