Healthcare Provider Details

I. General information

NPI: 1356330278
Provider Name (Legal Business Name): JON E FITZPATRICK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 12/25/2021
Certification Date: 12/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 CLEVELAND AVE STE A
SANTA ROSA CA
95403-2779
US

IV. Provider business mailing address

2655 CLEVELAND AVE STE A
SANTA ROSA CA
95403-2779
US

V. Phone/Fax

Practice location:
  • Phone: 707-545-7350
  • Fax: 707-546-7787
Mailing address:
  • Phone: 707-545-7350
  • Fax: 707-546-7787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number7949T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: