Healthcare Provider Details

I. General information

NPI: 1164266128
Provider Name (Legal Business Name): IBRAHIM ABDEL QADER IBRAHIM KHRAIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date: 03/07/2025
Reactivation Date: 07/24/2025

III. Provider practice location address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-6400
  • Fax: 414-955-0213
Mailing address:
  • Phone: 414-805-6400
  • Fax: 414-955-0213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number3015681
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number3015681
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number87681-020
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number87681-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: