Provider Demographics
NPI:1043464431
Name:IBRAHIM, JIHAD Y (MD)
Entity type:Individual
Prefix:
First Name:JIHAD
Middle Name:Y
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 648
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-0648
Mailing Address - Country:US
Mailing Address - Phone:573-674-4470
Mailing Address - Fax:
Practice Address - Street 1:255 W HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:LICKING
Practice Address - State:MO
Practice Address - Zip Code:65542-9076
Practice Address - Country:US
Practice Address - Phone:573-674-4470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103766207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine