Healthcare Provider Details

I. General information

NPI: 1467256594
Provider Name (Legal Business Name): MICHAEL SHANE FITZGIBBONS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2025
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 LIBERTY VIEW LN
LYNCHBURG VA
24502-2291
US

IV. Provider business mailing address

7 WINDSWEPT CIR
BREWSTER NY
10509-4900
US

V. Phone/Fax

Practice location:
  • Phone: 434-592-6400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number112703
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: