Healthcare Provider Details

I. General information

NPI: 1275275513
Provider Name (Legal Business Name): JUNAID EBRAHIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2022
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PERSHING AVE
SHENANDOAH IA
51601-2355
US

IV. Provider business mailing address

726 OAK RIDGE DR
GLENWOOD IA
51534-1869
US

V. Phone/Fax

Practice location:
  • Phone: 580-458-1948
  • Fax:
Mailing address:
  • Phone: 580-458-1948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD55082
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: