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General NPI Number Information
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NPI Number | 1255151478
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Entity Type | Individual
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Provider Name | IBRAHIM A FEYISSA MD
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Gender | Male
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Dates
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Enumeration Date | 10/14/2024
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Last Update Date | 10/14/2024
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Provider Practice Location Address
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Address Line | 619 N PROVIDENCE RD
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City | COLUMBIA
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State | MO
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Zip | 65203-4355
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Country | US
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Telephone | 573-234-1070
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Fax | 573-818-1342
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Provider Business Mailing Address
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Address Line | 2401 W BROADWAY APT 824
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City | COLUMBIA
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State | MO
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Zip | 65203-7620
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Country | US
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Telephone | 240-839-8224
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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 | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 2023038187
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License Number State | MO
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