Provider Demographics
NPI:1952314759
Name:FITZGERALD, THERESA ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:ANN
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 ROWENA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-2042
Mailing Address - Country:US
Mailing Address - Phone:323-660-2370
Mailing Address - Fax:323-663-4100
Practice Address - Street 1:2904 ROWENA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-2042
Practice Address - Country:US
Practice Address - Phone:323-660-2370
Practice Address - Fax:323-663-4100
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20181111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC20181Medicare ID - Type UnspecifiedMEDICARE
CAU19497Medicare UPIN