Provider Demographics
NPI:1306815972
Name:FITZ, JOHN R (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:FITZ
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 1:140 WESTMOUNT DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-2970
Mailing Address - Country:US
Mailing Address - Phone:573-756-2020
Mailing Address - Fax:573-756-6997
Practice Address - Street 1:140 WESTMOUNT DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-2970
Practice Address - Country:US
Practice Address - Phone:573-756-2020
Practice Address - Fax:573-756-6997
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD R2D32207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202056719Medicaid
MO990000982Medicare ID - Type Unspecified
MO202056719Medicaid