Provider Demographics
NPI:1851359566
Name:DAVID LAUREN FITZGERALD OD PA
Entity Type:Organization
Organization Name:DAVID LAUREN FITZGERALD OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:252-756-4204
Mailing Address - Street 1:3450 S CONTENTNEA ST
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27828-1686
Mailing Address - Country:US
Mailing Address - Phone:252-753-3325
Mailing Address - Fax:252-753-2057
Practice Address - Street 1:3450 S CONTENTNEA ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:NC
Practice Address - Zip Code:27828-1686
Practice Address - Country:US
Practice Address - Phone:252-753-3325
Practice Address - Fax:252-753-2057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0455290001OtherDMERC
NC562054972OtherCHAMPUS
NC0250QOtherBCBS
NC890250QMedicaid
NCU25125Medicare UPIN
NC2470610Medicare PIN
NC562054972OtherTAX ID