Provider Demographics
NPI:1841231834
Name:FITZGERALD, THOMAS M (DPM)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:M
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:THOMAS
Other - Middle Name:MICHAEL
Other - Last Name:FITZGERALD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:1350 MEDICAL CENTER DRIVE
Mailing Address - Street 2:STE B
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928
Mailing Address - Country:US
Mailing Address - Phone:707-586-9300
Mailing Address - Fax:707-586-1252
Practice Address - Street 1:1350 MEDICAL CENTER DRIVE
Practice Address - Street 2:STE B
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928
Practice Address - Country:US
Practice Address - Phone:707-586-9300
Practice Address - Fax:707-586-1252
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3409213E00000X, 213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E34090Medicaid
CA000E34090OtherBLUE SHIELD
CA680159845OtherBLUE CROSS
CA000E34090Medicaid
CA000E34090Medicare PIN
CA000E34090OtherBLUE SHIELD