Healthcare Provider Details

I. General information

NPI: 1114488418
Provider Name (Legal Business Name): BRIAN IBABAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

500 W MAIN ST STE 16
WYCKOFF NJ
07481-1406
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-4321
  • Fax:
Mailing address:
  • Phone: 201-847-9320
  • Fax: 201-847-0059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA11741700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: