Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 4714 | KY |
NPI | 1558466656 |
---|---|
Provider Name | Dr. Donald Lee Fitzgerald |
First Address | Louisville, KY 40214-1429 |
Second Address | Louisville, KY 40214-1429 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/09/2006 |
Last Update Date | 03/12/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000485925 | ANTHEM PIN (01) | KY |
2622354000 | (05) | KY |
50007516 | PASSPORT PROVIDER # (01) | KY |
666360 | ACN PROVIDER ID# (01) | KY |
V05155 | (02) | KY |