Basic Information
| Provider Information | |||||||||
| NPI: | 1073702627 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SORATHIA | ||||||||
| FirstName: | LUBNA | ||||||||
| MiddleName: | TAYYAB | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | GERIATRICS | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148056850 | ||||||||
| FaxNumber: | 4148056851 | ||||||||
| Practice Location | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | GERIATRICS | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148056850 | ||||||||
| FaxNumber: | 4148056851 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2007 | ||||||||
| LastUpdateDate: | 07/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 46195 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207RG0300X | 64303-20 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 92720234 | 05 | CO | MEDICAID |