Provider Demographics
NPI:1730295478
Name:FITZGERALD-SOAPES, S JAN (MD)
Entity Type:Individual
Prefix:
First Name:S
Middle Name:JAN
Last Name:FITZGERALD-SOAPES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3685 LAWRENCEVILLE HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-4107
Mailing Address - Country:US
Mailing Address - Phone:770-921-7386
Mailing Address - Fax:770-381-6013
Practice Address - Street 1:3685 LAWRENCEVILLE HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-4107
Practice Address - Country:US
Practice Address - Phone:770-921-7386
Practice Address - Fax:770-381-6013
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16509208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00416457BMedicaid
GA00416457CMedicaid