Provider Demographics
NPI:1427015056
Name:FITZPATRICK, JOHN PHILLIP (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PHILLIP
Last Name:FITZPATRICK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31338 LAKE VISTA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:BONSALL
Mailing Address - State:CA
Mailing Address - Zip Code:92003
Mailing Address - Country:US
Mailing Address - Phone:760-631-2050
Mailing Address - Fax:
Practice Address - Street 1:3044 HARDING ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008
Practice Address - Country:US
Practice Address - Phone:760-729-5921
Practice Address - Fax:760-729-4369
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT8185TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0081850OtherVSP MEDICAID
U28636Medicare UPIN
SD0081850OtherVSP MEDICAID
0853250002Medicare NSC