Provider Demographics
NPI:1811004385
Name:MEJALLI, NEDAL S (MD)
Entity Type:Individual
Prefix:DR
First Name:NEDAL
Middle Name:S
Last Name:MEJALLI
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 1:1238 S. CESAR E CHAVEZ DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-2267
Mailing Address - Country:US
Mailing Address - Phone:414-645-6664
Mailing Address - Fax:414-645-6732
Practice Address - Street 1:1238 S. CESAR E CHAVEZ DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-2267
Practice Address - Country:US
Practice Address - Phone:414-645-6664
Practice Address - Fax:414-645-6732
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35998207Q00000X
WI35998-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1811004385Medicaid
WI32091500Medicaid
WI1811004385Medicaid