Provider Demographics
NPI:1902867179
Name:FITZGERALD, SUSIE (DO)
Entity Type:Individual
Prefix:
First Name:SUSIE
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 260
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28329-0260
Mailing Address - Country:US
Mailing Address - Phone:910-596-5421
Mailing Address - Fax:910-596-5432
Practice Address - Street 1:607 BEAMAN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2603
Practice Address - Country:US
Practice Address - Phone:910-596-5421
Practice Address - Fax:910-596-5432
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2021-00367207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412455Medicaid
NC141J6OtherNCBCBS