Provider Demographics
NPI:1104921766
Name:CHAUDHRY, KHALID I (MD)
Entity type:Individual
Prefix:
First Name:KHALID
Middle Name:I
Last Name:CHAUDHRY
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 1:1351 ONTARIO RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8302
Mailing Address - Country:US
Mailing Address - Phone:920-328-1220
Mailing Address - Fax:920-469-7213
Practice Address - Street 1:100 N VILLAGE AVE
Practice Address - Street 2:SUITE 15
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3767
Practice Address - Country:US
Practice Address - Phone:347-247-9172
Practice Address - Fax:631-886-5700
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI663972084P0800X
NY2289762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02460979Medicaid
NY373BC1Medicare ID - Type Unspecified
NYI00251Medicare UPIN