1104921766 NPI number — KHALID I CHAUDHRY M.D.

Table of content: KHALID I CHAUDHRY M.D. (NPI 1104921766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104921766 NPI number — KHALID I CHAUDHRY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAUDHRY
Provider First Name:
KHALID
Provider Middle Name:
I
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104921766
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1351 ONTARIO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54311-8302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-328-1220
Provider Business Mailing Address Fax Number:
920-469-7213

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N VILLAGE AVE
Provider Second Line Business Practice Location Address:
SUITE 15
Provider Business Practice Location Address City Name:
ROCKVILLE CENTRE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11570-3767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-247-9172
Provider Business Practice Location Address Fax Number:
631-886-5700
Provider Enumeration Date:
09/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  66397 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084P0800X , with the licence number: 228976 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02460979 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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