Healthcare Provider Details

I. General information

NPI: 1376093716
Provider Name (Legal Business Name): TALAL M AL-QAOUD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 W JOHNSON ST
MADISON WI
53703-3471
US

IV. Provider business mailing address

309 W JOHNSON ST
MADISON WI
53703-3471
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number64809-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number64809
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number64809
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: