Basic Information
| Provider Information | |||||||||
| NPI: | 1396978979 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULTANA | ||||||||
| FirstName: | MUNAWAR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 E RACINE ST | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535462343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083718000 | ||||||||
| FaxNumber: | 6083718938 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 E RACINE ST | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535462343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083718000 | ||||||||
| FaxNumber: | 6083718938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2009 | ||||||||
| LastUpdateDate: | 07/31/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 68535-20 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | 125.056881 | IL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 261QF0400X | 036130663 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1396978979 | 05 | WI | MEDICAID |