Healthcare Provider Details

I. General information

NPI: 1770100497
Provider Name (Legal Business Name): ISHAAN JAKHAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 WAUBE LN
GREEN BAY WI
54304-5521
US

IV. Provider business mailing address

222 S WOODS MILL RD
CHESTERFIELD MO
63017-3625
US

V. Phone/Fax

Practice location:
  • Phone: 920-548-9500
  • Fax:
Mailing address:
  • Phone: 314-205-6050
  • Fax: 314-434-5939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2020019056
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number86098-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: