Provider Demographics
NPI:1003015363
Name:FISH, BRANDON (OD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
Last Name:FISH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 N COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3382
Mailing Address - Country:US
Mailing Address - Phone:208-734-3937
Mailing Address - Fax:208-734-7585
Practice Address - Street 1:731 N COLLEGE RD
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3382
Practice Address - Country:US
Practice Address - Phone:208-734-3937
Practice Address - Fax:208-734-7585
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP100141152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist