Provider Demographics
NPI:1194727859
Name:FITZGIBBONS, MICHAEL WARREN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WARREN
Last Name:FITZGIBBONS
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 62316
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-6077
Mailing Address - Country:US
Mailing Address - Phone:714-731-7871
Mailing Address - Fax:714-731-7872
Practice Address - Street 1:1913 E 17TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8627
Practice Address - Country:US
Practice Address - Phone:714-541-3744
Practice Address - Fax:714-541-4680
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34615207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA46004Medicare UPIN