Provider Demographics
NPI:1891859468
Name:ETTNER, FREDERIC MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERIC
Middle Name:MARK
Last Name:ETTNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7126 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-2234
Mailing Address - Country:US
Mailing Address - Phone:847-733-2229
Mailing Address - Fax:847-733-1528
Practice Address - Street 1:7126 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-2234
Practice Address - Country:US
Practice Address - Phone:847-733-2229
Practice Address - Fax:847-733-1528
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0136053752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL489690Medicare ID - Type UnspecifiedMEDICARE
ILC42312Medicare UPIN