Basic Information
| Provider Information | |||||||||
| NPI: | 1811381015 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FITZGERALD | ||||||||
| FirstName: | CODI | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2347 E GALA ST | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836424881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083233767 | ||||||||
| FaxNumber: | 2063233768 | ||||||||
| Practice Location | |||||||||
| Address1: | 2347 E GALA ST | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836424881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083233767 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2015 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | M-15948 | ID | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | MD60776152 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.