Provider Demographics
NPI:1679635171
Name:JANDALI, MAJED (MD)
Entity Type:Individual
Prefix:
First Name:MAJED
Middle Name:
Last Name:JANDALI
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 1:9555 76TH ST STE 4880
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-1984
Mailing Address - Country:US
Mailing Address - Phone:262-748-1001
Mailing Address - Fax:262-748-1020
Practice Address - Street 1:9555 76TH ST STE 4880
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1984
Practice Address - Country:US
Practice Address - Phone:262-748-1001
Practice Address - Fax:262-748-1020
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34339208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31923800Medicaid
WIE19827Medicare UPIN
WI31923800Medicaid