Healthcare Provider Details

I. General information

NPI: 1477528065
Provider Name (Legal Business Name): KHAWAJA A AMMAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 W KINNICKINNIC RIVER PKWY SUITE 175
MILWAUKEE WI
53215-3669
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 414-649-3626
  • Fax: 414-385-7157
Mailing address:
  • Phone: 414-389-2377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number53467
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number53467
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: