Healthcare Provider Details

I. General information

NPI: 1386631661
Provider Name (Legal Business Name): JAWAID QUDDUS MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 04/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6123 GREEN BAY ROAD SUITE 120
KENOSHA WI
53142-2927
US

IV. Provider business mailing address

6123 GREEN BAY ROAD SUITE 120
KENOSHA WI
53142-2927
US

V. Phone/Fax

Practice location:
  • Phone: 262-764-4390
  • Fax: 262-764-4396
Mailing address:
  • Phone: 262-764-4390
  • Fax: 262-764-4396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number45606-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: