Healthcare Provider Details

I. General information

NPI: 1366489098
Provider Name (Legal Business Name): MATTHEW A FITZER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850A TOWN CENTER PKWY SUITE 301
RESTON VA
20190-5851
US

IV. Provider business mailing address

1850A TOWN CENTER PKWY SUITE 301
RESTON VA
20190-5851
US

V. Phone/Fax

Practice location:
  • Phone: 703-709-9701
  • Fax: 703-709-8084
Mailing address:
  • Phone: 703-709-9701
  • Fax: 703-709-8084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2005010623
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101250534
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: