Provider Demographics
NPI:1316906506
Name:FISHER, GARY L (DC)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:FISHER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 N WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-9102
Mailing Address - Country:US
Mailing Address - Phone:260-665-3106
Mailing Address - Fax:
Practice Address - Street 1:2014 N WAYNE ST
Practice Address - Street 2:TRI STATE CHIROPRACTIC CLINIC PC
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-9102
Practice Address - Country:US
Practice Address - Phone:260-665-3106
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000350111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000240945OtherANTHEM BCBS PIN