Provider Demographics
NPI:1750475620
Name:RAZZAQ, ANJUM MOHAMMAD
Entity Type:Individual
Prefix:
First Name:ANJUM
Middle Name:MOHAMMAD
Last Name:RAZZAQ
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 1:3727 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-3182
Mailing Address - Country:US
Mailing Address - Phone:414-291-2626
Mailing Address - Fax:414-431-0050
Practice Address - Street 1:3727 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-3182
Practice Address - Country:US
Practice Address - Phone:414-291-2626
Practice Address - Fax:414-431-0050
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35065-20208D00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31989800Medicaid
WI31989800Medicaid
WIF74526Medicare UPIN