Provider Demographics
NPI:1912956178
Name:JAN, M FUAD (MD)
Entity Type:Individual
Prefix:DR
First Name:M
Middle Name:FUAD
Last Name:JAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MUHAMMAD
Other - Middle Name:F
Other - Last Name:JAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:975 PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-9201
Mailing Address - Country:US
Mailing Address - Phone:262-329-1000
Mailing Address - Fax:262-329-1001
Practice Address - Street 1:975 PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-9201
Practice Address - Country:US
Practice Address - Phone:262-329-1000
Practice Address - Fax:262-329-1001
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52145207RI0011X
WI52145-020207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1912956178Medicaid
WIK400133405Medicare PIN
WI1912956178Medicaid
WIK400134458Medicare PIN