Provider Demographics
NPI:1376644492
Name:FITZPATRICK, DALE WALTER (MD)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:WALTER
Last Name:FITZPATRICK
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 1:1717 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2808
Mailing Address - Country:US
Mailing Address - Phone:209-529-0531
Mailing Address - Fax:209-529-5219
Practice Address - Street 1:1717 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2808
Practice Address - Country:US
Practice Address - Phone:209-529-0531
Practice Address - Fax:209-529-5219
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB70553455OtherDEA NUMBER
CA00G659400Medicare ID - Type Unspecified
CAC48489Medicare UPIN