Healthcare Provider Details

I. General information

NPI: 1760497226
Provider Name (Legal Business Name): EDWIN ISHOO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE BROOKLINE PLACE SUITE 321
BROOKLINE MA
02445
US

IV. Provider business mailing address

100 TRAPELO RD APT 1
WALTHAM MA
02452-6329
US

V. Phone/Fax

Practice location:
  • Phone: 781-552-6089
  • Fax:
Mailing address:
  • Phone: 781-552-6089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2005-0084
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number154977
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number154977
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number154977
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberMD2005-0084
License Number StateNM
# 6
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number154977
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: