Basic Information
| Provider Information | |||||||||
| NPI: | 1154593945 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ISTANBOLI | ||||||||
| FirstName: | MOHAMAD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 73652 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441930002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063303404 | ||||||||
| FaxNumber: | 6063303100 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 N EAGLE CREEK DR | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405091805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599675000 | ||||||||
| FaxNumber: | 6063303100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2008 | ||||||||
| LastUpdateDate: | 10/19/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084V0102X | 41634 | KY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology |
ID Information
| ID | Type | State | Issuer | Description | 7100063770 | 05 | KY | MEDICAID |