Provider Demographics
NPI:1780692095
Name:FITCH, BRIAN DUANE (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:DUANE
Last Name:FITCH
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:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:901 CAMPUS DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-4930
Practice Address - Country:US
Practice Address - Phone:415-642-0707
Practice Address - Fax:650-755-8638
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2017-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39679207L00000X
GUM-1953207L00000X
CAC55198207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO25002384Medicaid
COH43267Medicare UPIN
CO25002384Medicaid
CO439048Medicare PIN