Healthcare Provider Details

I. General information

NPI: 1306272372
Provider Name (Legal Business Name): AHMAD A MAQBOUL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2013
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 KEPLER DR
GREEN BAY WI
54311-8321
US

IV. Provider business mailing address

1160 KEPLER DR
GREEN BAY WI
54311-8321
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-5400
  • Fax:
Mailing address:
  • Phone: 920-288-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301104344
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6626-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: