Provider Demographics
NPI:1720406325
Name:ISSAK, ABDULFATAH ABDUL (MD)
Entity Type:Individual
Prefix:
First Name:ABDULFATAH
Middle Name:ABDUL
Last Name:ISSAK
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 1:3400 OLENTANGY RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1523
Mailing Address - Country:US
Mailing Address - Phone:614-754-5500
Mailing Address - Fax:614-754-5501
Practice Address - Street 1:3400 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43202-1523
Practice Address - Country:US
Practice Address - Phone:614-754-5500
Practice Address - Fax:614-754-5501
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH129731207R00000X
390200000X
OH35129731207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0218537Medicaid