Provider Demographics
NPI:1417272667
Name:GHADIALI, MOHSIN YUNUS (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHSIN
Middle Name:YUNUS
Last Name:GHADIALI
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 1:6 N PARK ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-2561
Mailing Address - Country:US
Mailing Address - Phone:630-991-6713
Mailing Address - Fax:630-991-6713
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5031
Practice Address - Country:US
Practice Address - Phone:414-290-6720
Practice Address - Fax:414-290-6755
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI63593-202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP01698310OtherRAILROAD MEDICARE
WIK400311783Medicare PIN