Provider Demographics
NPI:1245263110
Name:FITZGERALD, KEVIN R (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:R
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 29 1/2 RD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81504-5383
Mailing Address - Country:US
Mailing Address - Phone:970-248-6984
Mailing Address - Fax:
Practice Address - Street 1:510 29 1/2 RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81504-5383
Practice Address - Country:US
Practice Address - Phone:970-248-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30381207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01303817Medicaid
COF130025OtherBC/BS
CO01303817Medicaid
COE74382Medicare UPIN