Provider Demographics
NPI:1205828985
Name:DISHER, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:DISHER
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 1:9604 COLDWATER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2096
Mailing Address - Country:US
Mailing Address - Phone:260-387-5820
Mailing Address - Fax:855-828-7823
Practice Address - Street 1:9604 COLDWATER RD STE 101
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2096
Practice Address - Country:US
Practice Address - Phone:260-387-5820
Practice Address - Fax:855-828-7823
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 078705207Y00000X
IN01044624A207Y00000X, 207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200091970Medicaid
OH0232297Medicaid
OHDI4251001Medicare PIN
IN040009427Medicare PIN
OH0232297Medicaid
IN200091970Medicaid