Healthcare Provider Details

I. General information

NPI: 1871586560
Provider Name (Legal Business Name): FERNANDO T. ITABLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 11/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2745 W LAYTON AVE SUITE 3201
MILWAUKEE WI
53221-2651
US

IV. Provider business mailing address

PO BOX 689711
MILWAUKEE WI
53268-9711
US

V. Phone/Fax

Practice location:
  • Phone: 414-281-0050
  • Fax: 414-281-0773
Mailing address:
  • Phone: 414-456-3100
  • Fax: 414-456-3113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35585
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: