Healthcare Provider Details

I. General information

NPI: 1467442566
Provider Name (Legal Business Name): DOUGLAS FITZWATER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 02/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 WARD AVE
CARUTHERSVILLE MO
63830-1451
US

IV. Provider business mailing address

PO BOX 817
CAPE GIRARDEAU MO
63702-0817
US

V. Phone/Fax

Practice location:
  • Phone: 573-333-0033
  • Fax: 573-333-2522
Mailing address:
  • Phone: 573-335-4715
  • Fax: 573-334-2303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS S FITZWATER
Title or Position: MD OWNER
Credential: MD
Phone: 573-333-0033