MEDICARE: MR. GERALD LEE FITZGERALD JR. NAVY IDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1245498484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GERALD LEE FITZGERALD JR. NAVY IDC

Provider Business Mailing Address
First Line	:	SURFACE WARFARE MEDICINE INSTITUTE
Second Line	:	3401 FARENHOLT AVENUE
City	:	SAN DIEGO
State	:	CA
Zip	:	92134-0001
Country	:	US
Telephone Number	:	808-375-1486
Fax Number	:	619-532-5156

Provider Business Practice Location Address
First Line	:	SURFACE WARFARE MEDICINE INSTITUTE
Second Line	:	3401 FARENHOLT AVENUE
City	:	SAN DIEGO
State	:	CA
Zip	:	92134-0001
Country	:	US
Telephone Number	:	808-375-1486
Fax Number	:	619-532-5156

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2008
Last Update Date	:	01/26/2010

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Directions to “ MR. GERALD LEE FITZGERALD JR. NAVY IDC” Practice Location

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