Healthcare Provider Details

I. General information

NPI: 1043259880
Provider Name (Legal Business Name): IHAB J. IBRAHIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JEFFERSON BARRACKS DR
SAINT LOUIS MO
63125-4181
US

IV. Provider business mailing address

1 JEFFERSON BARRACKS DR
SAINT LOUIS MO
63125-4181
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax: 314-845-5077
Mailing address:
  • Phone: 314-652-4100
  • Fax: 314-845-5077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberMD.14699R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberMA78363
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: