Healthcare Provider Details

I. General information

NPI: 1366401960
Provider Name (Legal Business Name): IBRAHIM J HADDAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 05/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7641 MARKET ST STE 3
BOARDMAN OH
44512
US

IV. Provider business mailing address

PO BOX 3349
BOARDMAN OH
44513-3349
US

V. Phone/Fax

Practice location:
  • Phone: 330-729-9140
  • Fax:
Mailing address:
  • Phone: 330-729-9140
  • Fax: 330-729-9144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberMD045935L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number35-062494
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberA44109
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberMD2014-0041
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number35062494H
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: