Provider Demographics
NPI:1639284706
Name:FITZSIMMONS, MARK R (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:FITZSIMMONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:1475 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074
Practice Address - Country:US
Practice Address - Phone:262-268-5100
Practice Address - Fax:262-268-5118
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33627207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31986200Medicaid
WI31986200Medicaid
WI462364649Medicare PIN
670100045Medicare ID - Type UnspecifiedMEDICARE PROVIDER
WI019940416Medicare PIN