Healthcare Provider Details

I. General information

NPI: 1184642670
Provider Name (Legal Business Name): FERIDOUN BEROUKHIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 S 90TH ST STE 504
WEST ALLIS WI
53227-2455
US

IV. Provider business mailing address

2448 S 102ND ST STE 125
WEST ALLIS WI
53227-2466
US

V. Phone/Fax

Practice location:
  • Phone: 414-328-8670
  • Fax:
Mailing address:
  • Phone: 414-328-3809
  • Fax: 414-328-3818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18648
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: