Provider Demographics
NPI:1194717629
Name:FITZSIMMONS, RAYMOND JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:JOHN
Last Name:FITZSIMMONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1519
Mailing Address - Street 2:
Mailing Address - City:WHITE SALMON
Mailing Address - State:WA
Mailing Address - Zip Code:98672-1519
Mailing Address - Country:US
Mailing Address - Phone:509-493-2133
Mailing Address - Fax:509-493-9538
Practice Address - Street 1:212 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:WHITE SALMON
Practice Address - State:WA
Practice Address - Zip Code:98672
Practice Address - Country:US
Practice Address - Phone:509-493-2133
Practice Address - Fax:509-493-9538
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019686207Q00000X
ORMD14052207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA080036317OtherPTAN
WA8627309Medicaid
WA8627309Medicaid
WA000680902Medicare ID - Type Unspecified
WA503835Medicare Oscar/Certification
WAA15900Medicare UPIN