Provider Demographics
NPI:1366100216
Name:FITZGERALD, RODERICK
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 PRICE HAIRSTON LANE
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-1793
Mailing Address - Country:US
Mailing Address - Phone:276-336-5634
Mailing Address - Fax:
Practice Address - Street 1:625 PRICE HAIRSTON LANE
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1793
Practice Address - Country:US
Practice Address - Phone:276-336-5634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT63313780172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver