Provider Demographics
NPI:1124151394
Name:FISHER, JOHNNIE G (MD)
Entity type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:G
Last Name:FISHER
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 1:2700 CITIZENS PLZ
Mailing Address - Street 2:SUITE 300
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-5754
Mailing Address - Country:US
Mailing Address - Phone:361-578-8633
Mailing Address - Fax:
Practice Address - Street 1:2700 CITIZENS PLZ
Practice Address - Street 2:SUITE 300
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-5754
Practice Address - Country:US
Practice Address - Phone:361-578-8633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD70362084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB95619Medicare UPIN
TX00QM33Medicare ID - Type Unspecified