Provider Demographics
NPI:1619967106
Name:FITZWATER, DOUGLAS STEWART (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:STEWART
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 1:1008 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5044
Mailing Address - Country:US
Mailing Address - Phone:573-472-7406
Mailing Address - Fax:573-472-7475
Practice Address - Street 1:204 E 3RD ST
Practice Address - Street 2:
Practice Address - City:PORTAGEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63873-1402
Practice Address - Country:US
Practice Address - Phone:573-379-5467
Practice Address - Fax:573-379-5671
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8N022080P0204X, 208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO7158OtherBCBS
F00802Medicare UPIN
MO597191204Medicaid
MO268901Medicare Oscar/Certification
MO597191204Medicaid