=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154783397
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABDULLAH IBISH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2016
-----------------------------------------------------
Last Update Date | 08/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17360 BROOKHURST ST
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-3720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-772-4000
-----------------------------------------------------
Fax | 901-227-3206
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17360 BROOKHURST ST
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-3720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 901-227-3206
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | A168155
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 31762
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------