Provider Demographics
NPI:1902058555
Name:ITAGAKI, MICHAEL W (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
Last Name:ITAGAKI
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 1:1035 KEPLER DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8320
Mailing Address - Country:US
Mailing Address - Phone:920-301-1327
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-4848
Practice Address - Fax:920-288-4956
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD601253322085R0202X, 2085R0204X
CAA991972085R0202X
WI81016-202085R0202X
WI810162085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI685050Medicaid
WI100212024Medicaid
WA2023112Medicaid
WA305309OtherLNI PROVIDER ID
WA314444OtherLNI PROVIDER ID
WAG8914255Medicare PIN
WAG8914253Medicare PIN
WAG8914256Medicare PIN
WAG8914254Medicare PIN
HIFE375ZMedicare PIN
WAG8914252Medicare PIN