Provider Demographics
NPI:1609812569
Name:JAMIL, TAHA (MD)
Entity Type:Individual
Prefix:
First Name:TAHA
Middle Name:
Last Name:JAMIL
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 1:4916 N WATERFORD DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-6608
Mailing Address - Country:US
Mailing Address - Phone:920-733-1786
Mailing Address - Fax:
Practice Address - Street 1:4916 N WATERFORD DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-6608
Practice Address - Country:US
Practice Address - Phone:920-733-1786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52090-020208100000X
IN01062459A2081P2900X
IL036-1171762081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN141980BBMedicare ID - Type Unspecified
INI63690Medicare UPIN