1578513941 NPI number — DR. JOHN BRADLEY FITZWATER M.D.

Table of content: VANESSA TRUJILLO (NPI 1124522669)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578513941 NPI number — DR. JOHN BRADLEY FITZWATER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZWATER
Provider First Name:
JOHN
Provider Middle Name:
BRADLEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578513941
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12221 MOPAC EXPRESSWAY NORTH
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78758-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-901-2533
Provider Business Mailing Address Fax Number:
512-459-0404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1015 E 32ND ST
Provider Second Line Business Practice Location Address:
SUITE 306
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78705-2707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-459-1200
Provider Business Practice Location Address Fax Number:
512-459-0404
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  L0174 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0006MH . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 141250405 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 141250406 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7269218 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 10035722 . This is a "AMERIGROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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