Basic Information
| Provider Information | |||||||||
| NPI: | 1689253460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IBRAHIM | ||||||||
| FirstName: | MINA | ||||||||
| MiddleName: | RAFED | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6248 BRANFORD DR | ||||||||
| Address2: | |||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483221088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485130906 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11885 E 12 MILE RD STE 202A | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488654444 | ||||||||
| FaxNumber: | 2488656161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2021 | ||||||||
| LastUpdateDate: | 04/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.