Healthcare Provider Details

I. General information

NPI: 1164735122
Provider Name (Legal Business Name): MUHAMMAD AMEEN WASIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2010
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 S HENNEPIN AVE
DIXON IL
61021-3083
US

IV. Provider business mailing address

102 S HENNEPIN AVE
DIXON IL
61021-3083
US

V. Phone/Fax

Practice location:
  • Phone: 815-285-8908
  • Fax: 815-285-8903
Mailing address:
  • Phone: 815-285-8908
  • Fax: 815-285-8903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number63153-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125057570
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number63153-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: