Provider Demographics
NPI:1225196710
Name:FABRIQUE, KEITH LEWIS (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:LEWIS
Last Name:FABRIQUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1750 E LAKE SHORE DR
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521
Mailing Address - Country:US
Mailing Address - Phone:217-425-2732
Mailing Address - Fax:217-425-4778
Practice Address - Street 1:1750 E LAKE SHORE DR
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521
Practice Address - Country:US
Practice Address - Phone:217-425-2732
Practice Address - Fax:217-425-4778
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036050458207Q00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E24631Medicare UPIN