Provider Demographics
NPI:1073578951
Name:FICHTENBAUM, CARL JACK (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:JACK
Last Name:FICHTENBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2830 VICTORY PKWY
Mailing Address - Street 2:STE 310
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-3700
Mailing Address - Country:US
Mailing Address - Phone:513-245-3444
Mailing Address - Fax:513-245-3449
Practice Address - Street 1:200 ALBERT SABIN WAY
Practice Address - Street 2:# 405
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45267-2800
Practice Address - Country:US
Practice Address - Phone:513-584-6977
Practice Address - Fax:513-584-6040
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35-076757207R00000X, 207RI0200X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2147484Medicaid
KY64005580Medicaid
OH010064796OtherRAIL ROAD MEDICARE
IN200252570Medicaid
E80503Medicare UPIN
KY64005580Medicaid