Provider Demographics
NPI:1063618544
Name:YAGHMAI, ELISHA NAVID (MD)
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:NAVID
Last Name:YAGHMAI
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 1:425 N BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3810
Mailing Address - Country:US
Mailing Address - Phone:972-561-0067
Mailing Address - Fax:800-924-8140
Practice Address - Street 1:4723 E DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1012
Practice Address - Country:US
Practice Address - Phone:800-924-8140
Practice Address - Fax:800-924-8140
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS046825207Q00000X
KS04-33447207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201121110CMedicaid
WAG8942872Medicare PIN
KSKA3636005Medicare PIN