Provider Demographics
NPI:1669407748
Name:FITZPATRICK, KENNETH J (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:FITZPATRICK
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 1:640 CLOVELLY LN
Mailing Address - Street 2:
Mailing Address - City:DEVON
Mailing Address - State:PA
Mailing Address - Zip Code:19333
Mailing Address - Country:US
Mailing Address - Phone:484-431-5718
Mailing Address - Fax:
Practice Address - Street 1:640 CLOVELLY LN
Practice Address - Street 2:
Practice Address - City:DEVON
Practice Address - State:PA
Practice Address - Zip Code:19333-1847
Practice Address - Country:US
Practice Address - Phone:484-431-5718
Practice Address - Fax:484-480-2987
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01088523A208800000X
PAMD056906L208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG88101Medicare UPIN
024742M9EMedicare ID - Type Unspecified