Provider Demographics
NPI:1124438411
Name:FABIAN, MADONNA
Entity type:Individual
Prefix:
First Name:MADONNA
Middle Name:
Last Name:FABIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MADONNA
Other - Middle Name:
Other - Last Name:FABIAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3078 NILES ROAD
Mailing Address - Street 2:
Mailing Address - City:ST JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8608
Mailing Address - Country:US
Mailing Address - Phone:323-547-2155
Mailing Address - Fax:
Practice Address - Street 1:3078 NILES ROAD
Practice Address - Street 2:
Practice Address - City:ST JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8608
Practice Address - Country:US
Practice Address - Phone:269-287-3949
Practice Address - Fax:269-408-8631
Is Sole Proprietor?:No
Enumeration Date:2014-05-07
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036143635207R00000X
IL036.143635208M00000X
MI4301501470207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist