Healthcare Provider Details

I. General information

NPI: 1376899393
Provider Name (Legal Business Name): SAMEER TOLAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 E DIVISION ST
FOND DU LAC WI
54935-3734
US

IV. Provider business mailing address

420 E DIVISION ST
FOND DU LAC WI
54935-4560
US

V. Phone/Fax

Practice location:
  • Phone: 920-926-4100
  • Fax: 920-926-4190
Mailing address:
  • Phone: 920-926-8340
  • Fax: 920-926-8370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number68436
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: