=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508284126
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AHMED MOHAMED SAID IBRAHIM M.D., PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2014
-----------------------------------------------------
Last Update Date | 05/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 765 N WICKHAM RD STE 102
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32935-8869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-559-7800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 765 N WICKHAM RD STE 102
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32935-8869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-559-7800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | ME138139
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------