Provider Demographics
NPI:1053390823
Name:FITZGERALD, DWIGHT MELVIN (MD)
Entity type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:MELVIN
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3513 GRAYSTONE PL
Mailing Address - Street 2:
Mailing Address - City:CONOVER
Mailing Address - State:NC
Mailing Address - Zip Code:28613-8201
Mailing Address - Country:US
Mailing Address - Phone:828-322-8485
Mailing Address - Fax:828-322-5039
Practice Address - Street 1:3513 GRAYSTONE PL
Practice Address - Street 2:
Practice Address - City:CONOVER
Practice Address - State:NC
Practice Address - Zip Code:28613-8201
Practice Address - Country:US
Practice Address - Phone:828-322-8485
Practice Address - Fax:828-322-5039
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20792208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8932264Medicaid
C80870Medicare UPIN
201744CMedicare ID - Type Unspecified