Healthcare Provider Details

I. General information

NPI: 1912131749
Provider Name (Legal Business Name): JOHN P. FITZGERALD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2009
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 RESEARCH WAY SUITE 500
EAST SETAUKET NY
11733-3487
US

IV. Provider business mailing address

PO BOX 1559
STONY BROOK NY
11790-0989
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-6270
  • Fax: 631-444-6256
Mailing address:
  • Phone: 631-444-0650
  • Fax: 631-638-4170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number71159
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number262035-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: