Provider Demographics
NPI:1578524864
Name:ISSA, EBRAHIM
Entity Type:Individual
Prefix:DR
First Name:EBRAHIM
Middle Name:
Last Name:ISSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4420
Mailing Address - Country:US
Mailing Address - Phone:201-907-0995
Mailing Address - Fax:201-907-0996
Practice Address - Street 1:800 GRANGE RD
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4420
Practice Address - Country:US
Practice Address - Phone:201-907-0995
Practice Address - Fax:201-907-0996
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2013-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJMA71809174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE62920Medicare UPIN
NJ078065Medicare ID - Type Unspecified