Provider Demographics
NPI:1215053517
Name:ORTEGA, FABIO (MD)
Entity type:Individual
Prefix:
First Name:FABIO
Middle Name:
Last Name:ORTEGA
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 1:2650 RIDGE AVE ROOM 1223
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1057
Mailing Address - Country:US
Mailing Address - Phone:847-570-2040
Mailing Address - Fax:847-733-5315
Practice Address - Street 1:6810 N. MCCORMICK BLVD.
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712
Practice Address - Country:US
Practice Address - Phone:847-933-1773
Practice Address - Fax:847-679-1505
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065413207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065413Medicaid
ILD15729Medicare UPIN