Provider Demographics
NPI:1699877803
Name:FITZGERALD, MICHAEL T
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3375 PARK AVE
Mailing Address - Street 2:4000
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-3733
Mailing Address - Country:US
Mailing Address - Phone:516-221-8838
Mailing Address - Fax:516-221-4709
Practice Address - Street 1:3375 PARK AVE
Practice Address - Street 2:4000
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-3733
Practice Address - Country:US
Practice Address - Phone:516-221-8838
Practice Address - Fax:516-221-4709
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01140001103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV2B03Medicare UPIN