Provider Demographics
NPI:1992360804
Name:NADERI, NEDA
Entity Type:Individual
Prefix:
First Name:NEDA
Middle Name:
Last Name:NADERI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 MARKET LN
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-3430
Mailing Address - Country:US
Mailing Address - Phone:262-551-4600
Mailing Address - Fax:262-551-4635
Practice Address - Street 1:3400 MARKET LN
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-3430
Practice Address - Country:US
Practice Address - Phone:262-551-4600
Practice Address - Fax:262-551-4635
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI81033207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program