Healthcare Provider Details

I. General information

NPI: 1003826892
Provider Name (Legal Business Name): RODRIGO ITABLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2745 W LAYTON AVE SUITE 201
MILWAUKEE WI
53221-2651
US

IV. Provider business mailing address

5714 GLADSTONE LN
GREENDALE WI
53129-1511
US

V. Phone/Fax

Practice location:
  • Phone: 414-281-0050
  • Fax: 414-281-0733
Mailing address:
  • Phone: 414-529-3448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20287
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: