Provider Demographics
NPI:1225180680
Name:FISH, JASON S (MD, MSHS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:S
Last Name:FISH
Suffix:
Gender:M
Credentials:MD, MSHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UT SOUTHWESTERN MEDICAL CTR
Mailing Address - Street 2:5303 HARRY HINES BLVD
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-9124
Mailing Address - Country:US
Mailing Address - Phone:214-645-8620
Mailing Address - Fax:
Practice Address - Street 1:UT SOUTHWESTERN MEDICAL CTR
Practice Address - Street 2:5323 HARRY HINES BLVD
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-9126
Practice Address - Country:US
Practice Address - Phone:214-648-2383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90442207R00000X
TXP0382207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A904420Medicaid
CA00A904420Medicaid