Provider Demographics
NPI:1063493559
Name:FISH, RANDOLPH CHARLES (DPM)
Entity Type:Individual
Prefix:MR
First Name:RANDOLPH
Middle Name:CHARLES
Last Name:FISH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 SO. 76TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-2902
Mailing Address - Country:US
Mailing Address - Phone:253-584-9530
Mailing Address - Fax:360-427-2769
Practice Address - Street 1:915 SO. 76TH ST.
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-2902
Practice Address - Country:US
Practice Address - Phone:253-584-9530
Practice Address - Fax:360-427-2769
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA91-1813864213EP1101X
WAPO00000297213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2041494Medicaid
WA2041490Medicaid
WA2041490Medicaid
WAAB01980Medicare UPIN
WA4972490001Medicare NSC
WA2041494Medicaid
T11570Medicare UPIN