Provider Demographics
NPI:1073505160
Name:FITZGERALD, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:FITZGERALD
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 1:340 E PALM LN
Mailing Address - Street 2:SUITE 175
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-4603
Mailing Address - Country:US
Mailing Address - Phone:602-386-1100
Mailing Address - Fax:602-386-1150
Practice Address - Street 1:340 E PALM LN
Practice Address - Street 2:SUITE 175
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-4603
Practice Address - Country:US
Practice Address - Phone:602-386-1100
Practice Address - Fax:602-386-1150
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10590207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ060025521OtherRAILROAD MEDICARE
AZ225682Medicaid
AZ225682Medicaid
AZA42003Medicare UPIN