Provider Demographics
NPI:1285690321
Name:FITZGERALD, REBECCA LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LOUIS
Last Name:FITZGERALD
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:PO BOX 2866
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90509-2866
Mailing Address - Country:US
Mailing Address - Phone:310-792-0601
Mailing Address - Fax:310-792-9062
Practice Address - Street 1:321 N LARCHMONT BLVD
Practice Address - Street 2:SUITE 906
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3025
Practice Address - Country:US
Practice Address - Phone:323-464-8046
Practice Address - Fax:323-464-1832
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49000207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A490000OtherBLUE SHIELD
CAA49000Medicare ID - Type Unspecified
CAG34722Medicare UPIN