Provider Demographics
NPI:1366489098
Name:FITZER, MATTHEW A (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:FITZER
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 1:1850A TOWN CENTER PKWY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5851
Mailing Address - Country:US
Mailing Address - Phone:703-709-9701
Mailing Address - Fax:703-709-8084
Practice Address - Street 1:1850A TOWN CENTER PKWY
Practice Address - Street 2:SUITE 301
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5851
Practice Address - Country:US
Practice Address - Phone:703-709-9701
Practice Address - Fax:703-709-8084
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005010623208600000X
VA0101250534208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207411307Medicaid
MO207411307Medicaid
MO932951108Medicare ID - Type Unspecified