MEDICARE: DR. JAWAID QUDDUS MD, PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	45606-020	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386631661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAWAID QUDDUS MD, PHD

Provider Business Mailing Address
First Line	:	6123 GREEN BAY ROAD
Second Line	:	SUITE 120
City	:	KENOSHA
State	:	WI
Zip	:	53142-2927
Country	:	US
Telephone Number	:	262-764-4390
Fax Number	:	262-764-4396

Provider Business Practice Location Address
First Line	:	6123 GREEN BAY ROAD
Second Line	:	SUITE 120
City	:	KENOSHA
State	:	WI
Zip	:	53142-2927
Country	:	US
Telephone Number	:	262-764-4390
Fax Number	:	262-764-4396

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2005
Last Update Date	:	04/01/2011

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