MEDICARE: DR. IBRAHIM AHMAD TANGOREN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	209386	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770578601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IBRAHIM AHMAD TANGOREN M.D.

Provider Business Mailing Address
First Line	:	2949 ERIE BOULEVARD EAST
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13224-1460
Country	:	US
Telephone Number	:	315-579-9037
Fax Number	:	315-424-1779

Provider Business Practice Location Address
First Line	:	2949 ERIE BOULEVARD EAST
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13224-1460
Country	:	US
Telephone Number	:	315-579-9037
Fax Number	:	315-424-1779

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2005
Last Update Date	:	10/25/2016

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