Provider Demographics
NPI:1154372506
Name:FISCHER, KENNETH CLYDE (MD)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:CLYDE
Last Name:FISCHER
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 1:1190 NW 95TH ST
Mailing Address - Street 2:STE 402
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33150
Mailing Address - Country:US
Mailing Address - Phone:305-696-7666
Mailing Address - Fax:305-694-0111
Practice Address - Street 1:1190 NW 95TH ST
Practice Address - Street 2:STE 402
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33150
Practice Address - Country:US
Practice Address - Phone:305-696-7666
Practice Address - Fax:305-694-0111
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00246752084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL035837100Medicaid
FL035837100Medicaid
92148Medicare ID - Type Unspecified