Healthcare Provider Details

I. General information

NPI: 1235163189
Provider Name (Legal Business Name): JANE RAMANUJAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANE JOHNSTON MD

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11430 N PORT WASHINGTON RD
MEQUON WI
53092-3414
US

IV. Provider business mailing address

11430 N PORT WASHINGTON RD
MEQUON WI
53092-3414
US

V. Phone/Fax

Practice location:
  • Phone: 262-518-1900
  • Fax:
Mailing address:
  • Phone: 262-518-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number48202
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: