Provider Demographics
NPI:1245287432
Name:DAVID LAUREN FITZGERALD OD PA
Entity type:Organization
Organization Name:DAVID LAUREN FITZGERALD OD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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 1:1100 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3564
Mailing Address - Country:US
Mailing Address - Phone:252-975-8040
Mailing Address - Fax:252-975-0772
Practice Address - Street 1:1100 W 15TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3564
Practice Address - Country:US
Practice Address - Phone:252-975-8040
Practice Address - Fax:252-975-0772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0194WOtherBCBSNC GROUP NUMBER
NC890194WMedicaid
NC890194WMedicaid
NC2469913AMedicare PIN