Provider Demographics
NPI:1144316910
Name:ITANI, MUHAMMAD M (MD)
Entity type:Individual
Prefix:
First Name:MUHAMMAD
Middle Name:M
Last Name:ITANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MOHAMAD
Other - Middle Name:M
Other - Last Name:ITANI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:700 S PARK ST
Mailing Address - Street 2:DEAN ST. MARY'S OUTPATIENT CENTER
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1830
Mailing Address - Country:US
Mailing Address - Phone:608-258-6975
Mailing Address - Fax:608-258-5222
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:DEAN ST. MARY'S OUTPATIENT CENTER
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1830
Practice Address - Country:US
Practice Address - Phone:608-258-6975
Practice Address - Fax:608-258-5222
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46126-020207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1144316910Medicaid
WI34994000Medicaid
WIP00727768Medicare PIN
WI34994000Medicaid