Provider Demographics
NPI:1093811622
Name:FISHER, DAVID EDISON (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:EDISON
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 1:1706 KYLE LANE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-7437
Mailing Address - Country:US
Mailing Address - Phone:909-389-7929
Mailing Address - Fax:909-794-7575
Practice Address - Street 1:1850 S. WATERMAN AVE,
Practice Address - Street 2:SUITE E
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408
Practice Address - Country:US
Practice Address - Phone:909-890-0977
Practice Address - Fax:909-382-4523
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36514174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0077430Medicaid
CAA36514OtherMEDICAL LICENSE NUMBER
CAGR0077430Medicaid
CAA28114Medicare UPIN