Provider Demographics
NPI:1801818646
Name:ISSA, KHALED
Entity Type:Individual
Prefix:DR
First Name:KHALED
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 1:30701 CLEMENS ROAD
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145
Mailing Address - Country:US
Mailing Address - Phone:440-617-1212
Mailing Address - Fax:440-617-1213
Practice Address - Street 1:30701 CLEMENS RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1074
Practice Address - Country:US
Practice Address - Phone:440-617-1212
Practice Address - Fax:440-617-1213
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35058319207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0844439Medicaid
OH100014941OtherRAILROAD MEDICARE
OH$$$$$$$$$00OtherBWC
OH0844439Medicaid
OHE95878Medicare UPIN
OHIS0698202Medicare Oscar/Certification