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General NPI Number Information
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NPI Number | 1376611251
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Entity Type | Individual
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Provider Name | FAHIM K IBRAHIM MD
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Gender | Male
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Dates
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Enumeration Date | 12/01/2006
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Last Update Date | 10/20/2011
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Provider Practice Location Address
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Address Line | 4190 24TH AVE SUITE 204
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City | FORT GRATIOT
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State | MI
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Zip | 48059-3882
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Country | US
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Telephone | 810-989-7702
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Fax | 810-989-7703
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Provider Business Mailing Address
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Address Line | 4190 24TH AVE SUITE 204
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City | FORT GRATIOT
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State | MI
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Zip | 48059-3882
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Country | US
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Telephone | 810-989-7702
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Fax | 810-989-7703
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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 | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | FI067033
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License Number State | MI
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