Provider Demographics
NPI:1467536987
Name:BISHARA, ISHAK (MD,)
Entity Type:Individual
Prefix:DR
First Name:ISHAK
Middle Name:
Last Name:BISHARA
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 1:2006 DURFEE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91733-3713
Mailing Address - Country:US
Mailing Address - Phone:626-442-5015
Mailing Address - Fax:626-442-7810
Practice Address - Street 1:2006 DURFEE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733-3713
Practice Address - Country:US
Practice Address - Phone:626-442-5015
Practice Address - Fax:626-442-7810
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA453810207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A453810Medicaid
CA00A453810Medicaid
CAE56853Medicare UPIN