Healthcare Provider Details

I. General information

NPI: 1265655245
Provider Name (Legal Business Name): MINA KHORSHIDI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10539 N HIDDEN CREEK CT
MEQUON WI
53092-8543
US

IV. Provider business mailing address

10539 N HIDDEN CREEK CT
MEQUON WI
53092-8543
US

V. Phone/Fax

Practice location:
  • Phone: 262-242-3565
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number44766
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: