Basic Information
| Provider Information | |||||||||
| NPI: | 1265759054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FITZGERALD | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 CUMBERLAND XING # 262 | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463832356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3057252524 | ||||||||
| FaxNumber: | 3175648399 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 CUMBERLAND XING # 262 | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463832356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2192994643 | ||||||||
| FaxNumber: | 2192671720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2010 | ||||||||
| LastUpdateDate: | 04/03/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 07001158A | IN | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 07001158B | IN | N | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | P01563138 | 01 | IN | RAILROAD MEDICARE | OTHER | 201166760 | 05 | IN | MEDICAID |