Provider Demographics
NPI:1386631661
Name:QUDDUS, JAWAID (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JAWAID
Middle Name:
Last Name:QUDDUS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6123 GREEN BAY ROAD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2927
Mailing Address - Country:US
Mailing Address - Phone:262-764-4390
Mailing Address - Fax:262-764-4396
Practice Address - Street 1:6123 GREEN BAY ROAD
Practice Address - Street 2:SUITE 120
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2927
Practice Address - Country:US
Practice Address - Phone:262-764-4390
Practice Address - Fax:262-764-4396
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45606-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34414100Medicaid
WI34414100Medicaid
WIH91649Medicare UPIN