Provider Demographics
NPI:1912708132
Name:FITZGERALD, JEFFREY STARKS SR
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:STARKS
Last Name:FITZGERALD
Suffix:SR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2236 GREENWOOD MEADOWS LN
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1335
Mailing Address - Country:US
Mailing Address - Phone:678-328-8419
Mailing Address - Fax:
Practice Address - Street 1:2236 GREENWOOD MEADOWS LN
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1335
Practice Address - Country:US
Practice Address - Phone:678-328-8419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA22014483172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty