=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770858540
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IBRAHIM DESSOUKY PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2012
-----------------------------------------------------
Last Update Date | 03/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 BALSAM LN
-----------------------------------------------------
City | LEVITTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11756-4802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-739-6979
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11443 142ND ST
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11436-1024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 018210
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------