Provider Demographics
NPI:1417988908
Name:AUSTIN-FITZPATRICK, SALLY ELIZABETH (OD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:ELIZABETH
Last Name:AUSTIN-FITZPATRICK
Suffix:
Gender:F
Credentials:OD
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 361
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06057
Mailing Address - Country:US
Mailing Address - Phone:860-379-7183
Mailing Address - Fax:860-738-0436
Practice Address - Street 1:# 2 BRIDGE AND MAIN STREET
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06057
Practice Address - Country:US
Practice Address - Phone:860-379-7183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT956152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004147163Medicaid
CTT22722Medicare UPIN
CT410000415Medicare ID - Type Unspecified
CT0765440001Medicare NSC