Healthcare Provider Details

I. General information

NPI: 1881645737
Provider Name (Legal Business Name): JOHN J FANGMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 07/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FROEDTERT & MED COLLEGE CLIN - EAST 9200 WEST WISCONSIN AVENUE
MILWAUKEE WI
53226
US

IV. Provider business mailing address

9200 W WISCONSIN AVE FROEDTERT & MED COLLEGE CLIN - EAST
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-3666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number48629
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: