Healthcare Provider Details

I. General information

NPI: 1104921766
Provider Name (Legal Business Name): KHALID I CHAUDHRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 E 1ST ST
FOND DU LAC WI
54935-4505
US

IV. Provider business mailing address

1351 ONTARIO RD
GREEN BAY WI
54311-8302
US

V. Phone/Fax

Practice location:
  • Phone: 920-929-3500
  • Fax: 920-929-3129
Mailing address:
  • Phone: 920-328-1220
  • Fax: 920-469-7213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number66397
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number228976
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: