Provider Demographics
NPI:1003826892
Name:ITABLE, RODRIGO (MD)
Entity Type:Individual
Prefix:DR
First Name:RODRIGO
Middle Name:
Last Name:ITABLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5714 GLADSTONE LN
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-1511
Mailing Address - Country:US
Mailing Address - Phone:414-529-3448
Mailing Address - Fax:
Practice Address - Street 1:2745 W LAYTON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-2651
Practice Address - Country:US
Practice Address - Phone:414-281-0050
Practice Address - Fax:414-281-0733
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20287207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine