Healthcare Provider Details

I. General information

NPI: 1689811861
Provider Name (Legal Business Name): FARZANEH MASOOL TONDKAR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2009
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10731 W FOREST HOME AVE
HALES CORNERS WI
53130-2555
US

IV. Provider business mailing address

10731 WEST FOREST HOME AVENUE
HALES CORNERS WI
53130-2555
US

V. Phone/Fax

Practice location:
  • Phone: 414-529-4600
  • Fax: 414-529-4689
Mailing address:
  • Phone: 414-529-4600
  • Fax: 414-529-4689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number52372020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number52372020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: