1134111776 NPI number — JON TODD FITZGERALD DPM

Table of content: JON TODD FITZGERALD DPM (NPI 1134111776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134111776 NPI number — JON TODD FITZGERALD DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZGERALD
Provider First Name:
JON
Provider Middle Name:
TODD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1134111776
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
543 3RD ST
Provider Second Line Business Mailing Address:
STE C1
Provider Business Mailing Address City Name:
LAKE OSWEGO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97034-3067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-636-9656
Provider Business Mailing Address Fax Number:
503-636-9657

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
543 3RD ST
Provider Second Line Business Practice Location Address:
STE C1
Provider Business Practice Location Address City Name:
LAKE OSWEGO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97034-3067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-636-9656
Provider Business Practice Location Address Fax Number:
503-636-9657
Provider Enumeration Date:
08/19/2005

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: 213E00000X , with the licence number:  DP00248 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3008597-02 . This is a "HMOO" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 067533 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: F627 . This is a "HEALTHNET" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 054399002 . This is a "BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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