Provider Demographics
NPI:1003948753
Name:FITZER, MELODY L (MD)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:L
Last Name:FITZER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 BLACKBERRY LN NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9760
Mailing Address - Country:US
Mailing Address - Phone:616-361-8697
Mailing Address - Fax:
Practice Address - Street 1:2700 BLACKBERRY LN NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9760
Practice Address - Country:US
Practice Address - Phone:616-361-8697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054365207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F71000OtherBCBS
MI104974600Medicaid
MI105194785Medicaid
MI0F71000OtherBCBS
MI105194785Medicaid
P44120007Medicare PIN