Provider Demographics
NPI:1154398972
Name:ISHAK, ANDREW WAHBA (O D)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:WAHBA
Last Name:ISHAK
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:866-795-4020
Practice Address - Street 1:360 E PULASKI HWY
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-6457
Practice Address - Country:US
Practice Address - Phone:410-398-5240
Practice Address - Fax:410-398-4762
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0965152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
203253YN2CMedicare PIN
T77375Medicare UPIN
203253YN2DMedicare PIN
237LMedicare ID - Type Unspecified