Healthcare Provider Details

I. General information

NPI: 1720870660
Provider Name (Legal Business Name): IBRAHIM DBAYBO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST STE 6A
DETROIT MI
48201-2153
US

IV. Provider business mailing address

4201 SAINT ANTOINE ST STE 9C
DETROIT MI
48201-2153
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4627
  • Fax:
Mailing address:
  • Phone: 313-745-5146
  • Fax: 313-966-7305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: