Healthcare Provider Details

I. General information

NPI: 1073578951
Provider Name (Legal Business Name): CARL JACK FICHTENBAUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ALBERT SABIN WAY # 405
CINCINNATI OH
45267-2800
US

IV. Provider business mailing address

2830 VICTORY PKWY STE 310
CINCINNATI OH
45206-3700
US

V. Phone/Fax

Practice location:
  • Phone: 513-584-6977
  • Fax: 513-584-6040
Mailing address:
  • Phone: 513-245-3444
  • Fax: 513-245-3449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-076757
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number35-076757
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35-076757
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: