Provider Demographics
NPI:1851417380
Name:PATRICK FITZGERALD OD PA
Entity Type:Organization
Organization Name:PATRICK FITZGERALD OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:865-765-1562
Mailing Address - Street 1:3219 TOPSIDE DR
Mailing Address - Street 2:
Mailing Address - City:KODAK
Mailing Address - State:TN
Mailing Address - Zip Code:37764-2354
Mailing Address - Country:US
Mailing Address - Phone:865-765-1562
Mailing Address - Fax:
Practice Address - Street 1:1414 PARKWAY
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-2845
Practice Address - Country:US
Practice Address - Phone:865-765-1562
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2791152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN11624916OtherCAQH
TN2175001OtherADVANTICA
FL088OtherFOPN
FL112546OtherEYEMED
FE29254OtherOPTUM VISION SPECTERA
FL078771000Medicaid
TN63520OtherDAVIS VISION
TN=========OtherSUPERIOR VISION
FL112546OtherEYEMED
TN63520OtherDAVIS VISION
TN=========OtherBCBSTN
FE29254OtherOPTUM VISION SPECTERA