Provider Demographics
NPI:1518311331
Name:ADEMAJ, AMARILDO
Entity Type:Individual
Prefix:
First Name:AMARILDO
Middle Name:
Last Name:ADEMAJ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 DE SOTO AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-6701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:195 DISCOVERY DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2862
Practice Address - Country:US
Practice Address - Phone:262-513-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI71657-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program