1841231834 NPI number — MR. THOMAS M FITZGERALD DPM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841231834 NPI number — MR. THOMAS M FITZGERALD DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZGERALD
Provider First Name:
THOMAS
Provider Middle Name:
M
Provider Name Prefix Text:
MR.
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:
FITZGERALD
Provider Other First Name:
THOMAS
Provider Other Middle Name:
MICHAEL
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPM
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1841231834
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1350 MEDICAL CENTER DRIVE
Provider Second Line Business Mailing Address:
STE B
Provider Business Mailing Address City Name:
ROHNERT PARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-586-9300
Provider Business Mailing Address Fax Number:
707-586-1252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1350 MEDICAL CENTER DRIVE
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
ROHNERT PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-586-9300
Provider Business Practice Location Address Fax Number:
707-586-1252
Provider Enumeration Date:
06/09/2006

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: 213E00000X , with the licence number:  E3409 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213EP1101X , with the licence number: E3409 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0103X , with the licence number: E3409 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000E34090 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000E34090 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 680159845 . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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