Healthcare Provider Details

I. General information

NPI: 1396712907
Provider Name (Legal Business Name): THORBJORN GUDJONSSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HIGHLAND AVE
MADISON WI
53792
US

IV. Provider business mailing address

8007 EXCELSIOR DR
MADISON WI
53717
US

V. Phone/Fax

Practice location:
  • Phone: 608-263-1530
  • Fax: 608-833-6932
Mailing address:
  • Phone: 608-829-5201
  • Fax: 608-833-6932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number38213
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: