Provider Demographics
NPI:1649299793
Name:WISHAH, KHOLOUD K (MD)
Entity type:Individual
Prefix:
First Name:KHOLOUD
Middle Name:K
Last Name:WISHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29160 CENTER RIDGE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-5225
Mailing Address - Country:US
Mailing Address - Phone:440-835-1899
Mailing Address - Fax:440-835-1855
Practice Address - Street 1:29160 CENTER RIDGE RD
Practice Address - Street 2:SUITE A
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5225
Practice Address - Country:US
Practice Address - Phone:440-835-1899
Practice Address - Fax:440-835-1855
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0764342080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000319445OtherANTHEM
OH2468664Medicaid
OH2468664Medicaid