Provider Demographics
NPI:1811248305
Name:FITZGERALD, MIKE
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2036 E CALLE MADERAS
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-2910
Mailing Address - Country:US
Mailing Address - Phone:480-650-6685
Mailing Address - Fax:480-461-0069
Practice Address - Street 1:2036 E CALLE MADERAS
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-2910
Practice Address - Country:US
Practice Address - Phone:480-650-6685
Practice Address - Fax:480-461-0069
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker