Provider Demographics
NPI:1487712378
Name:GARY W. FISHER O.D.,P.C.
Entity type:Organization
Organization Name:GARY W. FISHER O.D.,P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WELSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-465-5114
Mailing Address - Street 1:603 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANAMOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52205-1845
Mailing Address - Country:US
Mailing Address - Phone:319-462-4891
Mailing Address - Fax:
Practice Address - Street 1:603 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ANAMOSA
Practice Address - State:IA
Practice Address - Zip Code:52205-1845
Practice Address - Country:US
Practice Address - Phone:319-462-4891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332H00000X
IA1615152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA26791OtherBLUE CROSS BLUE SHIELD
IA0128033Medicaid
IA7386OtherMIDLANDS CHOICE
IA7386OtherMIDLANDS CHOICE