Provider Demographics
NPI:1184642670
Name:BEROUKHIM, FERIDOUN (MD)
Entity Type:Individual
Prefix:
First Name:FERIDOUN
Middle Name:
Last Name:BEROUKHIM
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 1:2448 S 102ND ST
Mailing Address - Street 2:STE 125
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2466
Mailing Address - Country:US
Mailing Address - Phone:414-328-3809
Mailing Address - Fax:414-328-3818
Practice Address - Street 1:2424 S 90TH ST
Practice Address - Street 2:STE 504
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2455
Practice Address - Country:US
Practice Address - Phone:414-328-8670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18648208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30922300Medicaid
WI30922300Medicaid