Provider Demographics
NPI:1225119159
Name:FITZPATRICK, MARY LA (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LA
Last Name:FITZPATRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 W GUADALUPE RD STE 108
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-3049
Mailing Address - Country:US
Mailing Address - Phone:480-633-6200
Mailing Address - Fax:480-654-6214
Practice Address - Street 1:1520 W GUADALUPE RD STE 108
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-3049
Practice Address - Country:US
Practice Address - Phone:480-633-6200
Practice Address - Fax:480-654-6214
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26832207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ106147OtherMEDICARE ID-PIN
AZZ106147OtherMEDICARE ID-PIN
AZZ106147Medicare PIN