Provider Demographics
NPI:1033143433
Name:FITZMAURICE, JEFFREY J (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
Last Name:FITZMAURICE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51242 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-4286
Mailing Address - Country:US
Mailing Address - Phone:586-350-3141
Mailing Address - Fax:
Practice Address - Street 1:51242 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-4286
Practice Address - Country:US
Practice Address - Phone:586-350-3141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003868152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0E02492OtherBCBS
MIP3614001Medicare PIN
MIU67302Medicare UPIN