Provider Demographics
NPI:1396716619
Name:FITZGERALD, DALLAS DUSTIN (OD)
Entity type:Individual
Prefix:DR
First Name:DALLAS
Middle Name:DUSTIN
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19738 SUNSET RDG
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64505-8560
Mailing Address - Country:US
Mailing Address - Phone:816-662-9222
Mailing Address - Fax:
Practice Address - Street 1:1605 S MAIN ST
Practice Address - Street 2:WAL-MART VISION CENTER
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2611
Practice Address - Country:US
Practice Address - Phone:660-562-0215
Practice Address - Fax:660-562-0217
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03343152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1396716619Medicaid
MO050599111OtherUNITED HEALTHCARE
MO313842429Medicaid
MO050599111OtherTRICARE WEST
MO25269097OtherBCBS
MO050599111OtherTRICARE WEST