Provider Demographics
NPI:1558366856
Name:EHTISHAM, ASAD (MD)
Entity Type:Individual
Prefix:DR
First Name:ASAD
Middle Name:
Last Name:EHTISHAM
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:PO BOX 43108
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85080-3108
Mailing Address - Country:US
Mailing Address - Phone:602-663-0993
Mailing Address - Fax:
Practice Address - Street 1:15396 N 83RD AVE STE E
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5627
Practice Address - Country:US
Practice Address - Phone:623-300-3684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY377362084N0400X, 2084V0102X
AZ480992084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000052152QOtherHUMANA - NNS
KY50028054OtherPASSPORT & PASSPORT ADV - NNS
KY109615OtherSIHO - NNS
KY000000639847OtherANTHEM - NNS
KY7100096130Medicaid
KY5128838OtherCIGNA - NNS
KY7601540OtherAETNA - NNS
IN200972890Medicaid
KS200329930AMedicaid
KY7100096130Medicaid
KS111082001Medicare PIN
KY000052152QOtherHUMANA - NNS
KY109615OtherSIHO - NNS
KS200329930AMedicaid
KYP00818545Medicare PIN
KY50028054OtherPASSPORT & PASSPORT ADV - NNS