Healthcare Provider Details

I. General information

NPI: 1780647321
Provider Name (Legal Business Name): AHMED RAZA IBRAHIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 OSLER DR
TOWSON MD
21204
US

IV. Provider business mailing address

900 ELKRIDGE LANDING RD FL 2
LINTHICUM MD
21090-2924
US

V. Phone/Fax

Practice location:
  • Phone: 410-337-1150
  • Fax: 410-337-1844
Mailing address:
  • Phone: 443-462-5010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD75502
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberD75502
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: