Provider Demographics
NPI:1376578518
Name:MOMIN, JAHANGIR A (MD)
Entity Type:Individual
Prefix:
First Name:JAHANGIR
Middle Name:A
Last Name:MOMIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3102 E PARKSIDE BLVD
Mailing Address - Street 2:#7
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-5607
Mailing Address - Country:US
Mailing Address - Phone:262-538-1406
Mailing Address - Fax:262-538-1406
Practice Address - Street 1:3102 E PARKSIDE BLVD
Practice Address - Street 2:#7
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-5607
Practice Address - Country:US
Practice Address - Phone:262-538-1406
Practice Address - Fax:262-538-1406
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2010-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI46733-020207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34503700Medicaid
WI711810002Medicare PIN
WII07825Medicare UPIN
WI402200002Medicare PIN