Provider Demographics
NPI:1861795965
Name:T J FITZGIBBONS MD INC
Entity type:Organization
Organization Name:T J FITZGIBBONS MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:FITZGIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-977-1211
Mailing Address - Street 1:1245 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 905
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4810
Mailing Address - Country:US
Mailing Address - Phone:213-977-1211
Mailing Address - Fax:213-977-0625
Practice Address - Street 1:1245 WILSHIRE BLVD
Practice Address - Street 2:SUITE 905
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4810
Practice Address - Country:US
Practice Address - Phone:213-977-1211
Practice Address - Fax:213-977-0625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-10
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG320252086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG32025OtherSTATE OF CA LICENSE
CAA91399Medicare UPIN