Healthcare Provider Details

I. General information

NPI: 1396186367
Provider Name (Legal Business Name): IBRAHIM ALSHAHROURI M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 RYAN ST STE 105
LAKE CHARLES LA
70601-6078
US

IV. Provider business mailing address

1800 RYAN ST STE 105
LAKE CHARLES LA
70601-6078
US

V. Phone/Fax

Practice location:
  • Phone: 337-439-4706
  • Fax: 337-439-8110
Mailing address:
  • Phone: 337-439-4706
  • Fax: 337-439-8110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number303115
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101264403
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: