Healthcare Provider Details

I. General information

NPI: 1750904561
Provider Name (Legal Business Name): THOMAS H FITZPATRICK IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CHARLOIS BLVD
WINSTON SALEM NC
27103-1522
US

IV. Provider business mailing address

1200 E BROAD ST STE 313
RICHMOND VA
23298-5058
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-3361
  • Fax: 336-768-4131
Mailing address:
  • Phone: 803-828-2875
  • Fax: 804-807-7951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2025-01757
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: