Provider Demographics
NPI:1275612343
Name:ISHAK, MAMDOUH LATIF (MD)
Entity Type:Individual
Prefix:DR
First Name:MAMDOUH
Middle Name:LATIF
Last Name:ISHAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:121 S WILKE ROAD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-1524
Mailing Address - Country:US
Mailing Address - Phone:847-398-4536
Mailing Address - Fax:847-398-4712
Practice Address - Street 1:121 S WILKE ROAD
Practice Address - Street 2:SUITE 110
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-1524
Practice Address - Country:US
Practice Address - Phone:847-398-4536
Practice Address - Fax:847-398-4712
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036041272207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036041272Medicaid
IL036041272Medicaid