Provider Demographics
NPI:1720143894
Name:BARUAH, JITENDRA (MD, SC)
Entity Type:Individual
Prefix:DR
First Name:JITENDRA
Middle Name:
Last Name:BARUAH
Suffix:
Gender:M
Credentials:MD, SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 S 16TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4537
Mailing Address - Country:US
Mailing Address - Phone:414-384-5581
Mailing Address - Fax:414-384-5644
Practice Address - Street 1:3201 S 16TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4537
Practice Address - Country:US
Practice Address - Phone:414-384-5581
Practice Address - Fax:414-384-5644
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22662-0202084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30288000Medicaid
WI30288000Medicaid
B51403Medicare UPIN