Provider Demographics
NPI:1649232059
Name:FITZGERALD, JOHN M (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:FITZGERALD
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 1:3040 AMSDELL RD
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-5835
Mailing Address - Country:US
Mailing Address - Phone:716-649-9000
Mailing Address - Fax:716-649-9005
Practice Address - Street 1:565 ABBOTT RD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14220-2039
Practice Address - Country:US
Practice Address - Phone:716-828-2399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2180392085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000528130001OtherBCBS
NY1609206OtherINDEPENDENT HEALTH
NYP00257184OtherRR MEDICARE
NY00027170405OtherUNIVERA HEALTHCARE
NY02648786Medicaid
NY050709000020OtherFIDELIS CARE OF NEW YORK
NY190443FFOtherPREFERRED CARE
NYP00257184OtherRR MEDICARE
NY02648786Medicaid
NYRA7451Medicare PIN
NYI35040Medicare UPIN