Provider Demographics
NPI:1467442566
Name:DOUGLAS FITZWATER
Entity Type:Organization
Organization Name:DOUGLAS FITZWATER
Other - Org Name:CARUTHERSVILLE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:S
Authorized Official - Last Name:FITZWATER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-333-0033
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-0817
Mailing Address - Country:US
Mailing Address - Phone:573-335-4715
Mailing Address - Fax:573-334-2303
Practice Address - Street 1:412 WARD AVE
Practice Address - Street 2:
Practice Address - City:CARUTHERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63830-1451
Practice Address - Country:US
Practice Address - Phone:573-333-0033
Practice Address - Fax:573-333-2522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO7158OtherBCBS
MO596113605Medicaid
MO596113605Medicaid