Provider Demographics
NPI:1194769620
Name:FITZGIBBON, JAMES DAVID (DC)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:DAVID
Last Name:FITZGIBBON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-4914
Mailing Address - Country:US
Mailing Address - Phone:631-956-1785
Mailing Address - Fax:
Practice Address - Street 1:364 S WELLWOOD AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4905
Practice Address - Country:US
Practice Address - Phone:631-956-3489
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008630111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMCO8630-8OtherWORKERS' COMP
NYU66979Medicare UPIN
NMCO8630-8OtherWORKERS' COMP