Provider Demographics
NPI:1760497226
Name:ISHOO, EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:ISHOO
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 1:100 TRAPELO RD
Mailing Address - Street 2:APT 1
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-6329
Mailing Address - Country:US
Mailing Address - Phone:781-552-6089
Mailing Address - Fax:
Practice Address - Street 1:ONE BROOKLINE PLACE
Practice Address - Street 2:SUITE 321
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445
Practice Address - Country:US
Practice Address - Phone:781-552-6089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2005-0084207Y00000X
MA154977207Y00000X, 207YS0123X, 207YX0007X, 208200000X
NMMD2005-0084207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2161133Medicaid
MA2161133Medicaid
MAA2852201Medicare UPIN
NM345601601Medicare ID - Type Unspecified