Provider Demographics
NPI:1689811861
Name:MASOOL TONDKAR, FARZANEH (MD)
Entity Type:Individual
Prefix:
First Name:FARZANEH
Middle Name:
Last Name:MASOOL TONDKAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10731 WEST FOREST HOME AVENUE
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-2555
Mailing Address - Country:US
Mailing Address - Phone:414-529-4600
Mailing Address - Fax:414-529-4689
Practice Address - Street 1:10731 W FOREST HOME AVE
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-2555
Practice Address - Country:US
Practice Address - Phone:414-529-4600
Practice Address - Fax:414-529-4689
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52372020208D00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1434Medicaid