Basic Information
| Provider Information | |||||||||
| NPI: | 1679520852 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAVID LAUREN FITZGERALD OD PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EYE CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5100 HWY 70 W | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285574504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527275290 | ||||||||
| FaxNumber: | 2527270091 | ||||||||
| Practice Location | |||||||||
| Address1: | 5100 HWY 70 W | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285574504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527275290 | ||||||||
| FaxNumber: | 2527270091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 08/18/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FITZGERALD | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2527564204 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 890922U | 05 | NC | MEDICAID | 0922U | 01 | NC | BCBSNC GROUP NUMBER | OTHER |