Provider Demographics
NPI:1265759054
Name:FITZGERALD, TIMOTHY ALAN (DPM)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ALAN
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 CUMBERLAND XING # 262
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2356
Mailing Address - Country:US
Mailing Address - Phone:305-725-2524
Mailing Address - Fax:317-564-8399
Practice Address - Street 1:1101 CUMBERLAND XING # 262
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2356
Practice Address - Country:US
Practice Address - Phone:219-299-4643
Practice Address - Fax:219-267-1720
Is Sole Proprietor?:No
Enumeration Date:2010-05-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001158A213E00000X
IN07001158B213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01563138OtherRAILROAD MEDICARE
IN201166760Medicaid
IN201166760Medicaid