Provider Demographics
NPI:1285818229
Name:MARCELIN, FITZGERALD SR (MD)
Entity Type:Individual
Prefix:
First Name:FITZGERALD
Middle Name:
Last Name:MARCELIN
Suffix:SR
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:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:VA
Mailing Address - Zip Code:23974-0070
Mailing Address - Country:US
Mailing Address - Phone:434-696-2165
Mailing Address - Fax:434-696-1557
Practice Address - Street 1:702 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847-1242
Practice Address - Country:US
Practice Address - Phone:434-634-7723
Practice Address - Fax:434-634-7725
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231381207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5861128Medicaid
VA1285818229Medicaid
NC89065FCMedicaid
VA1285818229Medicaid
NC89065FCMedicaid