MEDICARE: DR. FERNANDO T. ITABLE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	35585	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871586560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FERNANDO T. ITABLE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 689711
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53268-9711
Country	:	US
Telephone Number	:	414-456-3100
Fax Number	:	414-456-3113

Provider Business Practice Location Address
First Line	:	2745 W LAYTON AVE
Second Line	:	SUITE 3201
City	:	MILWAUKEE
State	:	WI
Zip	:	53221-2651
Country	:	US
Telephone Number	:	414-281-0050
Fax Number	:	414-281-0773

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	11/21/2008

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