Basic Information
| Provider Information | |||||||||
| NPI: | 1285690321 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FITZGERALD | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | LOUIS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2866 | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905092866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107920601 | ||||||||
| FaxNumber: | 3107929062 | ||||||||
| Practice Location | |||||||||
| Address1: | 321 N LARCHMONT BLVD | ||||||||
| Address2: | SUITE 906 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900043025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234648046 | ||||||||
| FaxNumber: | 3234641832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | A49000 | CA | X | Allopathic & Osteopathic Physicians | Dermatology | 207NS0135X | A49000 | CA | X | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 00A490000 | 01 | CA | BLUE SHIELD | OTHER |