Healthcare Provider Details

I. General information

NPI: 1295437994
Provider Name (Legal Business Name): THERESA BOYADJIAN MOKS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESA HAROUTIOUN BOYADJIAN MD

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3916 N INTERTECH CT
APPLETON WI
54913-6957
US

IV. Provider business mailing address

3916 N INTERTECH CT
APPLETON WI
54913-6957
US

V. Phone/Fax

Practice location:
  • Phone: 920-996-1000
  • Fax:
Mailing address:
  • Phone: 920-996-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8542020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: