Healthcare Provider Details

I. General information

NPI: 1770645012
Provider Name (Legal Business Name): MOFID KHALIL-IBRAHIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 04/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 GATES CIR
BUFFALO NY
14209-1120
US

IV. Provider business mailing address

3 GATES CIR
BUFFALO NY
14209-1120
US

V. Phone/Fax

Practice location:
  • Phone: 716-887-4093
  • Fax:
Mailing address:
  • Phone: 716-887-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number211652
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: