=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366489098
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW A FITZER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2006
-----------------------------------------------------
Last Update Date | 05/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1850A TOWN CENTER PKWY SUITE 301
-----------------------------------------------------
City | RESTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20190-5851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-709-9701
-----------------------------------------------------
Fax | 703-709-8084
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1850A TOWN CENTER PKWY SUITE 301
-----------------------------------------------------
City | RESTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20190-5851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-709-9701
-----------------------------------------------------
Fax | 703-709-8084
-----------------------------------------------------
=====================================================
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 | 2005010623
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 0101250534
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------