1558366856 NPI number — DR. ASAD EHTISHAM MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558366856 NPI number — DR. ASAD EHTISHAM MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

EHTISHAM

Provider First Name:

ASAD

Provider Middle Name:

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1558366856

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

08/07/2020

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 43108

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

PHOENIX

Provider Business Mailing Address State Name:

AZ

Provider Business Mailing Address Postal Code:

85080-3108

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

602-663-0993

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

15396 N 83RD AVE STE E

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

PEORIA

Provider Business Practice Location Address State Name:

AZ

Provider Business Practice Location Address Postal Code:

85381-5627

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

623-300-3684

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

06/15/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 2084N0400X , with the licence number:  37736 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2084N0400X , with the licence number: 48099 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 2084V0102X , with the licence number: 37736 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 000052152Q . This is a "HUMANA - NNS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 50028054 . This is a "PASSPORT & PASSPORT ADV - NNS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 109615 . This is a "SIHO - NNS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 000000639847 . This is a "ANTHEM - NNS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 7100096130 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
• Identifier: 5128838 . This is a "CIGNA - NNS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 7601540 . This is a "AETNA - NNS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 200972890 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
• Identifier: 200329930A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".