Provider Demographics
NPI:1417064965
Name:MATLOOB, AJMAL (MD)
Entity type:Individual
Prefix:
First Name:AJMAL
Middle Name:
Last Name:MATLOOB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1905 E. HUEBBE PARKWAY
Mailing Address - Street 2:BELOIT HEALTH SYSTEM INC.
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-2200
Mailing Address - Fax:608-363-7394
Practice Address - Street 1:1905 E. HUEBBE PARKWAY
Practice Address - Street 2:BELOIT HEALTH SYSTEM INC.
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1842
Practice Address - Country:US
Practice Address - Phone:608-364-2200
Practice Address - Fax:608-363-7394
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI30026020207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1417064965Medicaid
10652OtherDEAN HEALTH PLAN HMO
10652OtherDEAN HEALTH PLAN HMO