Healthcare Provider Details

I. General information

NPI: 1205399557
Provider Name (Legal Business Name): STEPHANIE ADEL IBRAHIM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 GASTON AVE STE 550
DALLAS TX
75246-1905
US

IV. Provider business mailing address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

V. Phone/Fax

Practice location:
  • Phone: 214-821-1177
  • Fax: 214-821-1193
Mailing address:
  • Phone: 210-358-4000
  • Fax: 210-358-0647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberT5581
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberT5581
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: