Provider Demographics
NPI:1508101775
Name:EHTISHAM NEUROVASCULAR INSTITUTE & AESTHESTICS P.A.
Entity Type:Organization
Organization Name:EHTISHAM NEUROVASCULAR INSTITUTE & AESTHESTICS P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AS'AD
Authorized Official - Middle Name:
Authorized Official - Last Name:EHTISHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-303-2153
Mailing Address - Street 1:6120 SHADYBROOK ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-1862
Mailing Address - Country:US
Mailing Address - Phone:316-633-4413
Mailing Address - Fax:877-381-0101
Practice Address - Street 1:3223 N WEBB RD
Practice Address - Street 2:SUITE 5
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-8175
Practice Address - Country:US
Practice Address - Phone:316-303-2153
Practice Address - Fax:877-381-0101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-313002084N0400X, 2084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular NeurologyGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty