Provider Demographics
NPI:1477551752
Name:FENTON, IRA F (DO)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:F
Last Name:FENTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1870 W WINCHESTER RD STE 112
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5365
Mailing Address - Country:US
Mailing Address - Phone:847-224-0165
Mailing Address - Fax:847-367-7345
Practice Address - Street 1:1870 W WINCHESTER RD STE 112
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5365
Practice Address - Country:US
Practice Address - Phone:847-224-0165
Practice Address - Fax:847-367-7345
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36058893207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC39500Medicare UPIN