Provider Demographics
NPI:1336134766
Name:FITZGERALD, THOMAS J (MD PH D)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:MD PH D
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 850
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-0146
Mailing Address - Country:US
Mailing Address - Phone:360-683-9895
Mailing Address - Fax:360-582-5614
Practice Address - Street 1:844 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3045
Practice Address - Country:US
Practice Address - Phone:360-683-9895
Practice Address - Fax:360-582-5614
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22612207RH0003X
FLME85034207RH0003X
WAMD60418114207RH0003X
ORMD181320207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264474600Medicaid
AL102I908108OtherMEDICARE PTAN
AL109804Medicaid
FL13519YOtherMEDICARE PTAN
FL12519WMedicare PIN