Provider Demographics
NPI:1356682652
Name:ISHAK, MARK-MINA MAHER (DO)
Entity Type:Individual
Prefix:
First Name:MARK-MINA
Middle Name:MAHER
Last Name:ISHAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NESCONSET HIGHWAY
Mailing Address - Street 2:BUILDING 18C
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790
Mailing Address - Country:US
Mailing Address - Phone:631-751-2700
Mailing Address - Fax:631-751-5853
Practice Address - Street 1:1771 TATE BLVD SE STE 101
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-4250
Practice Address - Country:US
Practice Address - Phone:828-304-2527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY296442207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program