Healthcare Provider Details

I. General information

NPI: 1609829613
Provider Name (Legal Business Name): FREDERICK B FITTS JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 HILAND AVE
BURLEY ID
83318-2682
US

IV. Provider business mailing address

PO BOX 1886
TWIN FALLS ID
83303-1886
US

V. Phone/Fax

Practice location:
  • Phone: 208-677-6513
  • Fax:
Mailing address:
  • Phone: 208-736-0887
  • Fax: 208-736-0890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberM6310
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: