1710942743 NPI number — CAROL S ISHAK MD

Table of content: CAROL S ISHAK MD (NPI 1710942743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710942743 NPI number — CAROL S ISHAK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ISHAK
Provider First Name:
CAROL
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

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 Information

NPI Number:
1710942743
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 MACK BLVD FL 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLENTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18103-5622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
484-884-4500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DICKSON CITY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18519-1691
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-884-4500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  026427 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: MD030695E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1710942743 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com