Provider Demographics
NPI:1982665600
Name:ISMAIL, MEDHAT (MD)
Entity Type:Individual
Prefix:DR
First Name:MEDHAT
Middle Name:
Last Name:ISMAIL
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 1:27 ALMADERA DR
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2471
Mailing Address - Country:US
Mailing Address - Phone:973-790-3433
Mailing Address - Fax:
Practice Address - Street 1:246 HAMBURG TPKE
Practice Address - Street 2:SUITE 208
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2156
Practice Address - Country:US
Practice Address - Phone:973-790-3433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA61414207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6738109Medicaid
NJ6738109Medicaid
NJG19642Medicare UPIN