Provider Demographics
NPI:1316683519
Name:AHMAD, ISHTIAQ (MD)
Entity type:Individual
Prefix:
First Name:ISHTIAQ
Middle Name:
Last Name:AHMAD
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 1:1000 E MOUNTAIN BLVD WILKES-BARRE, GEISINGER WYOMING VA
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18711
Mailing Address - Country:US
Mailing Address - Phone:570-808-7300
Mailing Address - Fax:570-808-5967
Practice Address - Street 1:1000 E MOUNTAIN BLVD WILKES-BARRE, GEISINGER WYOMING VA
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711
Practice Address - Country:US
Practice Address - Phone:570-808-7300
Practice Address - Fax:570-808-5967
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2023-03-27
Deactivation Date:2023-03-20
Deactivation Code:
Reactivation Date:2023-03-27
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMT225780390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program