Provider Demographics
NPI:1245498484
Name:FITZGERALD, GERALD LEE JR (NAVY IDC)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:LEE
Last Name:FITZGERALD
Suffix:JR
Gender:M
Credentials:NAVY IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SURFACE WARFARE MEDICINE INSTITUTE
Mailing Address - Street 2:3401 FARENHOLT AVENUE
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-0001
Mailing Address - Country:US
Mailing Address - Phone:808-375-1486
Mailing Address - Fax:619-532-5156
Practice Address - Street 1:SURFACE WARFARE MEDICINE INSTITUTE
Practice Address - Street 2:3401 FARENHOLT AVENUE
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-0001
Practice Address - Country:US
Practice Address - Phone:808-375-1486
Practice Address - Fax:619-532-5156
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman