Provider Demographics
NPI:1811947088
Name:SAMADANI, AYAZ M (MD)
Entity type:Individual
Prefix:
First Name:AYAZ
Middle Name:M
Last Name:SAMADANI
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 1:215 CORPORATE DR
Mailing Address - Street 2:SUITE H
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3123
Mailing Address - Country:US
Mailing Address - Phone:920-887-7731
Mailing Address - Fax:
Practice Address - Street 1:215 CORPORATE DR
Practice Address - Street 2:SUITE H
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3123
Practice Address - Country:US
Practice Address - Phone:920-887-7731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20554-020208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1001259OtherPHYSICIANS PLUS
WI17209OtherDEAN HEALTH INSURANCE
WI31059600Medicaid
WI31059600Medicaid
WI008154375Medicare PIN
WI007213215Medicare PIN
WI17209OtherDEAN HEALTH INSURANCE