Provider Demographics
NPI:1497939136
Name:MARK FITZGERALD, MD
Entity Type:Organization
Organization Name:MARK FITZGERALD, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-896-9792
Mailing Address - Street 1:123 CIBOLO CREEK DR
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-3216
Mailing Address - Country:US
Mailing Address - Phone:830-896-9792
Mailing Address - Fax:830-896-9751
Practice Address - Street 1:401 JUNCTION HWY
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-4202
Practice Address - Country:US
Practice Address - Phone:830-896-9792
Practice Address - Fax:830-896-9751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0467207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0067LYOtherBCBS
TX610838Medicare PIN
TX0067LYOtherBCBS