Provider Demographics
NPI:1588684781
Name:FITZPATRICK, THOMAS MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MARK
Last Name:FITZPATRICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BURNS
Mailing Address - State:OR
Mailing Address - Zip Code:97720-2014
Mailing Address - Country:US
Mailing Address - Phone:541-573-7988
Mailing Address - Fax:888-371-1993
Practice Address - Street 1:42 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BURNS
Practice Address - State:OR
Practice Address - Zip Code:97720-2014
Practice Address - Country:US
Practice Address - Phone:541-573-7988
Practice Address - Fax:888-371-1993
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00174380OtherRAILROAD MEDICARE
OR838331002OtherREGENCE BLUE CROSS
ORR151766OtherMEDICARE PTAN
OR009972Medicaid
ORA73135Medicare UPIN