Provider Demographics
NPI:1831176148
Name:FITZPATRICK, JOHN KEVIN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:KEVIN
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 1:147 MILK ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 HOLLAND ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-2705
Practice Address - Country:US
Practice Address - Phone:617-629-6330
Practice Address - Fax:617-629-6128
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206765207V00000X
MA242431207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0709873OtherIHA
NY0709873OtherIND. HEALTH
NY00010307609OtherUNIVERA
NY000525153011OtherBC/BS
NY452962OtherWELLCARE
NY00010307607OtherUNIVERA
NY000525153009OtherBC/BS
NY01775837Medicaid
NY040426000844OtherFIDELIS
NY050407000022OtherFIDELIS
NY111517CKOtherPREFERRED CARE
NY000525153011OtherBC/BS
NY00010307609OtherUNIVERA
NY111517CKOtherPREFERRED CARE
G74661Medicare UPIN
NY01775837Medicaid