Provider Demographics
NPI:1902981871
Name:ISHAC, ROGER (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:ISHAC
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 1:75 BEEKMAN ST.
Mailing Address - Street 2:CVPH CARDIOLOGY
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901
Mailing Address - Country:US
Mailing Address - Phone:518-563-2404
Mailing Address - Fax:
Practice Address - Street 1:75 BEEKMAN ST.
Practice Address - Street 2:CVPH CARDIOLOGY
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901
Practice Address - Country:US
Practice Address - Phone:518-563-2404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429478207R00000X
VT042.0013217207RC0000X
NY241066207RC0000X
PAMT189586390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD429478OtherPA MEDICAL LICENSE
PAMT189586OtherPA LICENSING DEPARTMENT