Provider Demographics
NPI:1053355834
Name:ISMAIL, MONA S (MD)
Entity type:Individual
Prefix:DR
First Name:MONA
Middle Name:S
Last Name:ISMAIL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1900
Mailing Address - Fax:
Practice Address - Street 1:766 HARTNESS RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3479
Practice Address - Country:US
Practice Address - Phone:704-380-3620
Practice Address - Fax:704-380-3623
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC202-040742084P0804X
NJ25MA075823002084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02395715Medicaid
NJ09969UT7Medicare ID - Type Unspecified
NY3X17515881Medicare ID - Type Unspecified
NY02395715Medicaid
NJ63929Medicare UPIN