Healthcare Provider Details

I. General information

NPI: 1942856778
Provider Name (Legal Business Name): MOHAMMAD OBAIDULLAH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 UNION AVE
SHEBOYGAN WI
53081-8426
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-8515
US

V. Phone/Fax

Practice location:
  • Phone: 920-802-2100
  • Fax:
Mailing address:
  • Phone: 920-802-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOT019678
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number100869
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number100869
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: