Provider Demographics
NPI:1568415743
Name:FITZGIBBONS, PATRICK L (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:L
Last Name:FITZGIBBONS
Suffix:
Gender:M
Credentials:MD
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 749241
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-9241
Mailing Address - Country:US
Mailing Address - Phone:714-446-7505
Mailing Address - Fax:714-446-7546
Practice Address - Street 1:101 E VALENCIA MESA DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3809
Practice Address - Country:US
Practice Address - Phone:714-446-7505
Practice Address - Fax:714-446-7546
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48387207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G483870Medicaid
CAWG48387EMedicare PIN
CAAN549ZMedicare PIN
CA00G483870Medicaid
CAE90845Medicare UPIN