Healthcare Provider Details

I. General information

NPI: 1184086928
Provider Name (Legal Business Name): IBRAHIM TAWHARI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF UTAH HOSPITAL 50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

5319 CITRUS BLVD APT NO. E133
RIVER RIDGE LA
70123-6154
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 862-754-6440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036149818
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036149818
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: