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General NPI Number Information
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NPI Number | 1376720813
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Entity Type | Organization
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Legal Business Name | WALEED IBRAHIM M.D., INC.
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Dates
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Enumeration Date | 01/28/2008
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Last Update Date | 01/28/2008
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Provider Practice Location Address
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Address Line | 999 S FAIRMONT AVE STE. 115
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City | LODI
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State | CA
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Zip | 95240-5100
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Country | US
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Telephone | 209-334-7559
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Fax | 209-334-7459
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Provider Business Mailing Address
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Address Line | 999 S FAIRMONT AVE STE. 115
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City | LODI
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State | CA
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Zip | 95240-5100
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Country | US
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Telephone | 209-334-7559
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Fax | 209-334-7459
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Authorized Official
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Title or Position | OWNER
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Name | DR. WALEED IBRAHIM
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Credential | M.D.
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Telephone | 209-334-7559
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | A77739
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License Number State | CA
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