Provider Demographics
NPI:1619228764
Name:GHISHAN, DANA FAWZI (MD)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:FAWZI
Last Name:GHISHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 QUAIL DR
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24605-9411
Mailing Address - Country:US
Mailing Address - Phone:520-664-7304
Mailing Address - Fax:
Practice Address - Street 1:500 CHERRY ST
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-3306
Practice Address - Country:US
Practice Address - Phone:304-327-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24903208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics