Healthcare Provider Details

I. General information

NPI: 1063764207
Provider Name (Legal Business Name): GILBERT ANTONIO JENOURI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2012
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5508 W CRAWFORD AVE
MILWAUKEE WI
53220-2059
US

IV. Provider business mailing address

5508 W CRAWFORD AVE
MILWAUKEE WI
53220-2059
US

V. Phone/Fax

Practice location:
  • Phone: 414-763-5928
  • Fax:
Mailing address:
  • Phone: 414-763-5928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number266123
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number266123
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number266123
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number266123
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: