Provider Demographics
NPI:1194962050
Name:ISMAIL, HESHAM M (PT, DPT, CSCS)
Entity type:Individual
Prefix:DR
First Name:HESHAM
Middle Name:M
Last Name:ISMAIL
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 S CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE ALFRED
Mailing Address - State:FL
Mailing Address - Zip Code:33850-2929
Mailing Address - Country:US
Mailing Address - Phone:863-521-6560
Mailing Address - Fax:
Practice Address - Street 1:290 S CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:LAKE ALFRED
Practice Address - State:FL
Practice Address - Zip Code:33850-2929
Practice Address - Country:US
Practice Address - Phone:863-521-6560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24475225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist