Provider Demographics
NPI:1821104100
Name:TIMOTHY A FITZER MD INC A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:TIMOTHY A FITZER MD INC A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:BERKELEY FAMILY PRACTICE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PALACIOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-841-1647
Mailing Address - Street 1:2636 TELEGRAPH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-3373
Mailing Address - Country:US
Mailing Address - Phone:510-841-1647
Mailing Address - Fax:510-848-4924
Practice Address - Street 1:2636 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-3322
Practice Address - Country:US
Practice Address - Phone:510-841-1647
Practice Address - Fax:510-848-4924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ92584ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER#