Provider Demographics
NPI:1174574412
Name:JAFAR, TAZEEN H (MD)
Entity type:Individual
Prefix:
First Name:TAZEEN
Middle Name:H
Last Name:JAFAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 E GRANT ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-3483
Mailing Address - Country:US
Mailing Address - Phone:920-731-4138
Mailing Address - Fax:
Practice Address - Street 1:1818 N MEADE ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3454
Practice Address - Country:US
Practice Address - Phone:920-735-7645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36342-020207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4554481OtherECFMG
WI34673500Medicaid
4554481OtherECFMG