Provider Demographics
NPI:1194930891
Name:FISHER, JEFFREY
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8545 COMMON RD
Mailing Address - Street 2:# 200
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-6772
Mailing Address - Country:US
Mailing Address - Phone:586-751-0732
Mailing Address - Fax:586-751-3822
Practice Address - Street 1:8545 COMMON RD
Practice Address - Street 2:# 200
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-6772
Practice Address - Country:US
Practice Address - Phone:586-751-0732
Practice Address - Fax:586-751-3822
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085699207R00000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine