Provider Demographics
NPI:1992099121
Name:FITZGERALD, MARK PATRICK (MD, PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:PATRICK
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 CIVIC CENTER BLVD
Mailing Address - Street 2:DIVISION OF NEUROLOGY
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-590-1719
Mailing Address - Fax:215-590-1771
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:DIVISION OF NEUROLOGY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-590-1719
Practice Address - Fax:215-590-1771
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT1989252084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology