Provider Demographics
NPI:1326008384
Name:AHMAD, ISHTIAQ (MD)
Entity Type:Individual
Prefix:
First Name:ISHTIAQ
Middle Name:
Last Name:AHMAD
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 1:1860 TOWN CENTER DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5896
Mailing Address - Country:US
Mailing Address - Phone:703-348-7207
Mailing Address - Fax:703-435-1844
Practice Address - Street 1:1860 TOWN CENTER DR
Practice Address - Street 2:SUITE 320
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5896
Practice Address - Country:US
Practice Address - Phone:703-348-7207
Practice Address - Fax:703-435-1844
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00613342084N0400X
VA2422084V0102X
VA0102302452084N0400X
VA3089204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010358906Medicaid
MD404642100Medicaid
6432-0001OtherCAREFIRST
VA010358906Medicaid
6432-0001OtherCAREFIRST
MD404642100Medicaid