Healthcare Provider Details

I. General information

NPI: 1669407649
Provider Name (Legal Business Name): MOHAMMED DODWAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 08/05/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 COLLEGE AVE W
LADYSMITH WI
54848-2116
US

IV. Provider business mailing address

5753 DAWLEY DR
FITCHBURG WI
53711-7221
US

V. Phone/Fax

Practice location:
  • Phone: 715-532-5561
  • Fax: 715-532-9809
Mailing address:
  • Phone: 608-276-9868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number36597
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier33310900
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: