Provider Demographics
NPI:1528221132
Name:FITZGERALD, RANDY LEE (OD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:LEE
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:30 MAIN ST
Practice Address - Street 2:SUITE 120
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-8438
Practice Address - Country:US
Practice Address - Phone:802-658-7610
Practice Address - Fax:802-864-0893
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030.0077067152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist