Provider Demographics
NPI:1578513941
Name:FITZWATER, JOHN BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRADLEY
Last Name:FITZWATER
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 1:12221 MOPAC EXPRESSWAY NORTH
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-0000
Mailing Address - Country:US
Mailing Address - Phone:512-901-2533
Mailing Address - Fax:512-459-0404
Practice Address - Street 1:1015 E 32ND ST
Practice Address - Street 2:SUITE 306
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-2707
Practice Address - Country:US
Practice Address - Phone:512-459-1200
Practice Address - Fax:512-459-0404
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0174207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0006MHOtherBLUE CROSS
TX141250405Medicaid
TX141250406Medicaid
TX7269218OtherAETNA
TX10035722OtherAMERIGROUP
TX141250405Medicaid
TX141250406Medicaid
TX8F9913Medicare PIN