Healthcare Provider Details

I. General information

NPI: 1952300899
Provider Name (Legal Business Name): TARIQ SHAKOOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 05/17/2021
Certification Date: 05/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1836 SOUTH AVE
LA CROSSE WI
54601-5429
US

IV. Provider business mailing address

4685 FOREST AVE
CINCINNATI OH
45212-3397
US

V. Phone/Fax

Practice location:
  • Phone: 608-782-7300
  • Fax:
Mailing address:
  • Phone: 513-853-4722
  • Fax: 513-852-8525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number32055
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number35.048678
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: