Basic Information
| Provider Information | |||||||||
| NPI: | 1316334246 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FITZGERALD | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 SAN MATEO BLVD SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871082921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054627333 | ||||||||
| FaxNumber: | 5054627314 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 SAN MATEO BLVD SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871082921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054627333 | ||||||||
| FaxNumber: | 5054627314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2015 | ||||||||
| LastUpdateDate: | 07/04/2019 | ||||||||
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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 | 208000000X | MD2018-0766 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.