Healthcare Provider Details

I. General information

NPI: 1417064965
Provider Name (Legal Business Name): AJMAL MATLOOB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 E. HUEBBE PARKWAY BELOIT HEALTH SYSTEM INC.
BELOIT WI
53511-1842
US

IV. Provider business mailing address

1905 E. HUEBBE PARKWAY BELOIT HEALTH SYSTEM INC.
BELOIT WI
53511-1842
US

V. Phone/Fax

Practice location:
  • Phone: 608-364-2200
  • Fax: 608-363-7394
Mailing address:
  • Phone: 608-364-2200
  • Fax: 608-363-7394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number30026020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: