Provider Demographics
NPI:1861475592
Name:FABRICIUS, THOMAS J (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:FABRICIUS
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 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:920-926-8370
Practice Address - Street 1:420 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-8200
Practice Address - Fax:920-926-8907
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45809207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34431700Medicaid
WIP00081643OtherRAILROAD MEDICARE
WI34431700Medicaid
WIWI01L1OtherJOHN DEERE
WI015422245Medicare ID - Type Unspecified
WI13552OtherDEAN
H17298Medicare UPIN