Provider Demographics
NPI:1912078007
Name:MOAZAM J SAMDANI MD SC
Entity Type:Organization
Organization Name:MOAZAM J SAMDANI MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOAZAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:SAMDANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-261-3333
Mailing Address - Street 1:123 HOSPITAL DR
Mailing Address - Street 2:#214
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098
Mailing Address - Country:US
Mailing Address - Phone:920-261-3333
Mailing Address - Fax:920-261-6955
Practice Address - Street 1:123 HOSPITAL DR
Practice Address - Street 2:#214
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098
Practice Address - Country:US
Practice Address - Phone:920-261-3333
Practice Address - Fax:920-261-6955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19713207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1000279OtherPHYSICIANS PLUS HMO
WI80OtherDEAN HEALTH PLAN
WI31092300Medicaid
WI1000279OtherPHYSICIANS PLUS HMO
WI30014Medicare ID - Type Unspecified