=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053390823
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DWIGHT MELVIN FITZGERALD MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2006
-----------------------------------------------------
Last Update Date | 03/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3513 GRAYSTONE PL
-----------------------------------------------------
City | CONOVER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28613-8201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-322-8485
-----------------------------------------------------
Fax | 828-322-5039
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3513 GRAYSTONE PL
-----------------------------------------------------
City | CONOVER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28613-8201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-322-8485
-----------------------------------------------------
Fax | 828-322-5039
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 20792
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------