Provider Demographics
NPI:1801954672
Name:ISSA, MAYADA HUSSAIN (MD)
Entity type:Individual
Prefix:
First Name:MAYADA
Middle Name:HUSSAIN
Last Name:ISSA
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 1:213 S JEFFERSON ST STE 625
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5516
Mailing Address - Fax:540-224-5684
Practice Address - Street 1:3 RIVERSIDE CIR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4955
Practice Address - Country:US
Practice Address - Phone:540-224-5170
Practice Address - Fax:540-983-8229
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22792207R00000X
MDD0058488174400000X
VA0101234451207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVIS6037141Medicare PIN