Healthcare Provider Details

I. General information

NPI: 1841235645
Provider Name (Legal Business Name): MATHEW S ISHO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 WASHINGTON ST SUITE 821
SAN DIEGO CA
92103-2213
US

IV. Provider business mailing address

4060 4TH AVE STE 510
SAN DIEGO CA
92103-2121
US

V. Phone/Fax

Practice location:
  • Phone: 619-686-4011
  • Fax: 619-686-4041
Mailing address:
  • Phone: 619-686-4011
  • Fax: 619-686-4041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberA93470
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: