Provider Demographics
NPI:1164735122
Name:WASIM, MUHAMMAD AMEEN (MD)
Entity Type:Individual
Prefix:
First Name:MUHAMMAD
Middle Name:AMEEN
Last Name:WASIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 S HENNEPIN AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3083
Mailing Address - Country:US
Mailing Address - Phone:815-285-8908
Mailing Address - Fax:815-285-8903
Practice Address - Street 1:102 S HENNEPIN AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3083
Practice Address - Country:US
Practice Address - Phone:815-285-8908
Practice Address - Fax:815-285-8903
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI63153-20208D00000X, 207Q00000X
IL125057570390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program