Provider Demographics
NPI:1831540350
Name:FITZGERALD, EVAN (MD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:FITZGERALD
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 1:13320 NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49097-1514
Mailing Address - Country:US
Mailing Address - Phone:269-649-2012
Mailing Address - Fax:
Practice Address - Street 1:13320 NORTH BLVD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MI
Practice Address - Zip Code:49097-1514
Practice Address - Country:US
Practice Address - Phone:269-649-2012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116029765207Q00000X
MI4301500376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine