Provider Demographics
NPI:1982019998
Name:ISSA, KIMONA (MD)
Entity Type:Individual
Prefix:
First Name:KIMONA
Middle Name:
Last Name:ISSA
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 1:23 MINNISINK RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-4810
Mailing Address - Country:US
Mailing Address - Phone:661-645-8397
Mailing Address - Fax:
Practice Address - Street 1:65 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-1651
Practice Address - Country:US
Practice Address - Phone:607-798-9356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-27
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY52114207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program