Provider Demographics
NPI:1255508487
Name:ITENBERG, EDWIN ROBERT (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:ROBERT
Last Name:ITENBERG
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:16001 W 9 MILE RD
Mailing Address - Street 2:FISHER BUILDING 3RD FLOOR
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4818
Mailing Address - Country:US
Mailing Address - Phone:248-849-6030
Mailing Address - Fax:248-849-6039
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:FISHER BUILDING 3RD FLOOR
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-6030
Practice Address - Fax:248-849-6039
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2012-12-05
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Provider Licenses
StateLicense IDTaxonomies
MI5101019112208C00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery