Provider Demographics
NPI:1871586560
Name:ITABLE, FERNANDO T (MD)
Entity type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:T
Last Name:ITABLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 689711
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53268-9711
Mailing Address - Country:US
Mailing Address - Phone:414-456-3100
Mailing Address - Fax:414-456-3113
Practice Address - Street 1:2745 W LAYTON AVE
Practice Address - Street 2:SUITE 3201
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-2651
Practice Address - Country:US
Practice Address - Phone:414-281-0050
Practice Address - Fax:414-281-0773
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI35585207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32260500Medicaid
WI001202475Medicare ID - Type Unspecified
WI045868480Medicare Oscar/Certification
WI32260500Medicaid
WI050073840Medicare Oscar/Certification