Provider Demographics
NPI:1720104706
Name:FERTIKH, MOUNIR (MD)
Entity Type:Individual
Prefix:
First Name:MOUNIR
Middle Name:
Last Name:FERTIKH
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 1:700 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1830
Mailing Address - Country:US
Mailing Address - Phone:608-260-2900
Mailing Address - Fax:608-260-2951
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715
Practice Address - Country:US
Practice Address - Phone:608-260-2900
Practice Address - Fax:608-260-2951
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI66855-20207RP1001X
KY46078207RP1001X
OH35.099980207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1720104706Medicaid
IN201206940Medicaid
KY7100257480Medicaid
IN201206940Medicaid
OH0081542Medicaid