Healthcare Provider Details

I. General information

NPI: 1972893766
Provider Name (Legal Business Name): DANIEL J. FITZGERALD, III, M.D., PROF. CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2011
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74075 EL PASEO SUITE B-1
PALM DESERT CA
92260-4118
US

IV. Provider business mailing address

74075 EL PASEO SUITE B-1
PALM DESERT CA
92260-4118
US

V. Phone/Fax

Practice location:
  • Phone: 760-346-4600
  • Fax: 760-346-6433
Mailing address:
  • Phone: 760-346-4600
  • Fax: 760-346-6433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG87039
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberG87039
License Number StateCA

VIII. Authorized Official

Name: LINDA VIRGINIA KEMMER
Title or Position: OFFICE MANAGER
Credential:
Phone: 760-346-4600