Provider Demographics
NPI:1114287893
Name:FITZSIMMONS, LARRY W (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:W
Last Name:FITZSIMMONS
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 1:7660 PINE PARK DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-9130
Mailing Address - Country:US
Mailing Address - Phone:616-975-9744
Mailing Address - Fax:
Practice Address - Street 1:7660 PINE PARK DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-9130
Practice Address - Country:US
Practice Address - Phone:616-975-9744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301030647207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MILF030647OtherMICHIGAN ID NUMBER