Healthcare Provider Details

I. General information

NPI: 1003360561
Provider Name (Legal Business Name): LAITH SHAMAN D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2016
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1271 N 6TH ST
MILWAUKEE WI
53212-3360
US

IV. Provider business mailing address

1271 N 6TH ST
MILWAUKEE WI
53212-3360
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-3666
  • Fax:
Mailing address:
  • Phone: 414-805-3666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1159-25
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: