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General NPI Number Information
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NPI Number | 1154741437
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Entity Type | Individual
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Provider Name | IHSAN ABDUL JABBAR PTA
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Gender | Male
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Dates
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Enumeration Date | 04/24/2014
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Last Update Date | 04/24/2014
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Provider Practice Location Address
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Address Line | 515 BRIGHTFIELD RD
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City | LUTHERVILLE
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State | MD
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Zip | 21093-3643
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Country | US
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Telephone | 410-832-2399
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Fax |
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Provider Business Mailing Address
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Address Line | 1705 MCCULLOH ST
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City | BALTIMORE
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State | MD
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Zip | 21217-3435
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Country | US
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Telephone | 410-952-4235
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | A2689
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License Number State | MD
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