Healthcare Provider Details

I. General information

NPI: 1205218609
Provider Name (Legal Business Name): WALID MOHAMED NAGEIB IBRAHIM M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date: 02/02/2016
Reactivation Date: 04/28/2016

III. Provider practice location address

1611 NW 12TH AVE # 1901
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1611 NW 12TH AVE # 1901
MIAMI FL
33136-1005
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-1111
  • Fax:
Mailing address:
  • Phone: 305-585-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME155768
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberME155768
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: