Provider Demographics
NPI:1811964836
Name:FITZGERALD, TIMOTHY (DO)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:DO
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 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-682-4111
Mailing Address - Fax:520-818-3630
Practice Address - Street 1:13395 N MARANA MAIN ST
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85653-7008
Practice Address - Country:US
Practice Address - Phone:520-682-4111
Practice Address - Fax:520-818-3630
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0320000477207Q00000X
AZ2471208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ285404Medicaid
AZ285404Medicaid
AZZ191148Medicare PIN