Provider Demographics
NPI:1265405617
Name:FITZGIBBONS, WILLIAM P (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:P
Last Name:FITZGIBBONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1908 N 203RD ST STE 2
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-2889
Mailing Address - Country:US
Mailing Address - Phone:402-289-4031
Mailing Address - Fax:402-289-3185
Practice Address - Street 1:1908 N 203RD ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-2889
Practice Address - Country:US
Practice Address - Phone:402-289-4031
Practice Address - Fax:402-289-3185
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE15830207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0903302OtherMEDIPASS
470710146OtherTAX I D
NE470710146-13Medicaid
1265405617OtherNPI
NE15830OtherLICENSE
NE15830OtherLICENSE
AF1196826OtherDEA #
NE095282FIMedicare ID - Type Unspecified