Provider Demographics
NPI:1083622666
Name:ABDULAL, GHUDRAN A (MD)
Entity Type:Individual
Prefix:
First Name:GHUDRAN
Middle Name:A
Last Name:ABDULAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GHUDRAN
Other - Middle Name:A
Other - Last Name:ABEDL-AL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:14555 W NATIONAL AVE
Practice Address - Street 2:SUITE 165
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4494
Practice Address - Country:US
Practice Address - Phone:262-827-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34617900Medicaid
WI019940742Medicare PIN
WI34617900Medicaid
WI007768700Medicare PIN
WI462364961Medicare PIN