1598495384 NPI number — DR. JACKSON RILEY FITZGERALD OD

Table of content: DR. JACKSON RILEY FITZGERALD OD (NPI 1598495384)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598495384 NPI number — DR. JACKSON RILEY FITZGERALD OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZGERALD
Provider First Name:
JACKSON
Provider Middle Name:
RILEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1598495384
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 S HILLSIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELK RIDGE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84651-8501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-669-3687
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 E 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AFTON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
83110-5027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-885-3975
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2022

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: 152W00000X , with the licence number:  548T , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: OPT-OPT-LIC-4481 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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