=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720057920
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LADAN MOSTAGHIMI TEHRANI MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2006
-----------------------------------------------------
Last Update Date | 01/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 E VETERANS ST
-----------------------------------------------------
City | TOMAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54660-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-872-8662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7433 ELMWOOD AVE
-----------------------------------------------------
City | MIDDLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53562-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 87-707-2216
-----------------------------------------------------
Fax | 608-827-6960
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 41718
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------