Provider Demographics
NPI:1629089222
Name:FITZGERALD, ELLEN DRURY (OD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:DRURY
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 OCILLA RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2213
Mailing Address - Country:US
Mailing Address - Phone:912-393-0005
Mailing Address - Fax:912-393-0058
Practice Address - Street 1:1329 OCILLA RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2213
Practice Address - Country:US
Practice Address - Phone:912-393-0005
Practice Address - Fax:912-393-0058
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002104152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA535526348BMedicaid
GA7298815OtherAETNA
GAVGA001714OtherAVESIS
GA52144366-003OtherBCBS
GA101527Medicaid
GA202177960OtherTAX ID
GAVGA001714OtherAVESIS
GA7298815OtherAETNA
GADD5270Medicare ID - Type UnspecifiedPALMETTO GBA RAILROAD MCR
GA101527Medicaid