Individual
DR. JACK AVAK TERTADIAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
5900 S. LAKE DRIVE, CUDAHY, WI 53110
(414) 489-4190
(414) 489-4015
Mailing address
PO BOX 735044, CHICAGO, IL 60673-5044
(800) 326-2250
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
34176-020
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
31953000
—
WI
Enumeration date
08/22/2006
Last updated
08/02/2024
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