Provider Demographics
NPI:1316941222
Name:ISON, MICHAEL GRUNDEL (MD, MS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GRUNDEL
Last Name:ISON
Suffix:
Gender:M
Credentials:MD, MS
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Other - First Name:
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Mailing Address - Street 1:16223 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:DERWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20855-2188
Mailing Address - Country:US
Mailing Address - Phone:617-306-1260
Mailing Address - Fax:
Practice Address - Street 1:3300 GALLOWS RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3307
Practice Address - Country:US
Practice Address - Phone:703-776-4001
Practice Address - Fax:703-776-7113
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA221230207RI0200X
VA0101230684207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5862540Medicaid
VAH29062Medicare UPIN