Healthcare Provider Details

I. General information

NPI: 1841713088
Provider Name (Legal Business Name): YOUSAF AJAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 S WEBSTER AVE
GREEN BAY WI
54301-2253
US

IV. Provider business mailing address

1821 S WEBSTER AVE
GREEN BAY WI
54301-2253
US

V. Phone/Fax

Practice location:
  • Phone: 920-497-4600
  • Fax:
Mailing address:
  • Phone: 920-497-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number76769-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number76769-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: