Provider Demographics
NPI:1073522397
Name:FISHER, ETHAN K (MD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:K
Last Name:FISHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 NORTH CENTER ST
Mailing Address - Street 2:#800
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-7406
Mailing Address - Country:US
Mailing Address - Phone:801-990-1911
Mailing Address - Fax:801-990-1912
Practice Address - Street 1:5121 S COTTONWOOD STREET
Practice Address - Street 2:INTERMOUNTAIN MEDICAL CENTER
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84157
Practice Address - Country:US
Practice Address - Phone:801-507-5248
Practice Address - Fax:801-733-5618
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT96-323265-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID100501227Medicaid
UTPRA04837OtherMOLINA
UT1502954OtherUMWA
UT8597445OtherWORKERS COMP FUND
WY112422600Medicaid
UT40044OtherPEHP
UT27753OtherHEALTHY U
ID805478500Medicaid
UT870545614FI2OtherEDUCATORS MUTUAL
UT281279OtherDMBA
UT2090168OtherUNITED HEALTHCARE
UTQM0000075886OtherALTIUS
UT107007882102OtherIHC
AZ820721Medicaid
UT281279OtherDMBA
UT27753OtherHEALTHY U
UT005532764Medicare ID - Type Unspecified