Provider Demographics
NPI:1134111776
Name:FITZGERALD, JON TODD (DPM)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:TODD
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 3RD ST
Mailing Address - Street 2:STE C1
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3067
Mailing Address - Country:US
Mailing Address - Phone:503-636-9656
Mailing Address - Fax:503-636-9657
Practice Address - Street 1:543 3RD ST
Practice Address - Street 2:STE C1
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3067
Practice Address - Country:US
Practice Address - Phone:503-636-9656
Practice Address - Fax:503-636-9657
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00248213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3008597-02OtherHMOO
OR067533Medicaid
ORF627OtherHEALTHNET
OR054399002OtherBLUE CROSS
OR054399002OtherBLUE CROSS
OR3008597-02OtherHMOO
OR0827050001Medicare NSC