Provider Demographics
NPI:1245899038
Name:QURESHI, AZAM AHMED (MD)
Entity type:Individual
Prefix:DR
First Name:AZAM
Middle Name:AHMED
Last Name:QURESHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:1515 RANDOLPH CT
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-8345
Practice Address - Country:US
Practice Address - Phone:920-683-5278
Practice Address - Fax:920-482-0359
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100818-875207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology