Provider Demographics
NPI:1760649602
Name:FITZGERALD, RYAN HUDSON (DPM)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:HUDSON
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 CIRCLE 75 PKWY SE STE 900
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3084
Mailing Address - Country:US
Mailing Address - Phone:678-426-2171
Mailing Address - Fax:404-446-1957
Practice Address - Street 1:132 RIVERSTONE TER STE 101
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114
Practice Address - Country:US
Practice Address - Phone:678-880-0036
Practice Address - Fax:404-481-4427
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC626213ES0103X
VA0103301013213ES0103X
GAPOD001364213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPD6265Medicaid
VA0636510001Medicare NSC
SCSC08897651Medicare PIN