Provider Demographics
NPI:1730152000
Name:FITZGERALD, MARY AMANDA (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:AMANDA
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:AMANDA
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, MHSA
Mailing Address - Street 1:P O BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-1841
Mailing Address - Country:US
Mailing Address - Phone:479-437-3449
Mailing Address - Fax:479-437-3449
Practice Address - Street 1:5701 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-1634
Practice Address - Country:US
Practice Address - Phone:870-779-2751
Practice Address - Fax:054-456-7651
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-6099207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202875852Medicaid
AR183760001Medicaid
AR5AC05Medicare UPIN
MO202875852Medicaid
AR183760001Medicaid