Provider Demographics
NPI:1689652653
Name:FESKE, WILLIAM IRA (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:IRA
Last Name:FESKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11995 SINGLETREE LN
Mailing Address - Street 2:STE 500
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5347
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:3395 MICHELSON DR
Practice Address - Street 2:APT 3418
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-4438
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL713132085R0202X
CAG731522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270762400Medicaid
31623WMedicare PIN
CABG193ZMedicare PIN
F11421Medicare UPIN