Healthcare Provider Details

I. General information

NPI: 1629690631
Provider Name (Legal Business Name): IDIL IBRAHIM M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date: 01/17/2022
Reactivation Date: 03/14/2022

III. Provider practice location address

2041 GEORGIA AVENUE WASHINGTON, NW
WASHINGTON DC
20060
US

IV. Provider business mailing address

2150 PENNSYLVANIA AVE NW
WASHINGTON DC
20037-3201
US

V. Phone/Fax

Practice location:
  • Phone: 202-865-1452
  • Fax: 202-865-7202
Mailing address:
  • Phone: 202-741-3000
  • Fax: 202-865-7202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberD0101248
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: