Healthcare Provider Details

I. General information

NPI: 1508207895
Provider Name (Legal Business Name): YAZHINI VALLATHARASU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E CAPITOL DR
APPLETON WI
54911
US

IV. Provider business mailing address

122 E COLLEGE AVE
APPLETON WI
54911-5794
US

V. Phone/Fax

Practice location:
  • Phone: 920-364-3600
  • Fax: 920-364-3900
Mailing address:
  • Phone: 920-996-3264
  • Fax: 920-830-5970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number6290420
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number62904
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: