Provider Demographics
NPI:1992876858
Name:FITZGERALD, THOMAS C (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:C
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6140 CHADWORTH WAY
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-8291
Mailing Address - Country:US
Mailing Address - Phone:317-826-0138
Mailing Address - Fax:
Practice Address - Street 1:3167 S STATE ROAD 3
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:IN
Practice Address - Zip Code:47362-1318
Practice Address - Country:US
Practice Address - Phone:765-597-0788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002815B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU81922Medicare UPIN