Provider Demographics
NPI:1629067269
Name:TAHSILDAR, HASSAN I (MD)
Entity Type:Individual
Prefix:DR
First Name:HASSAN
Middle Name:I
Last Name:TAHSILDAR
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:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:1580 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5751
Practice Address - Country:US
Practice Address - Phone:920-435-8326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI54846-020207RX0202X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
144620OtherAMERICAN BOARD OF INTERNAL MEDIDICE/MEDICAL ONCOLOGY
WIP00929276Medicare Oscar/Certification
WI030280032Medicare Oscar/Certification
WI002150242Medicare Oscar/Certification
WIP00929276Medicare Oscar/Certification
WI002150242Medicare Oscar/Certification
OH000000136596OtherANTHEM