Provider Demographics
NPI:1235593260
Name:DR TED Y FISHER A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DR TED Y FISHER A PROFESSIONAL CORPORATION
Other - Org Name:DESERT VEIN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TED
Authorized Official - Middle Name:YOSHIO
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-822-1957
Mailing Address - Street 1:628 G STREET
Mailing Address - Street 2:
Mailing Address - City:BRAWLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92227
Mailing Address - Country:US
Mailing Address - Phone:760-344-1101
Mailing Address - Fax:760-344-4985
Practice Address - Street 1:628 G ST
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-2544
Practice Address - Country:US
Practice Address - Phone:760-344-1101
Practice Address - Fax:760-344-4985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-06
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52523261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00220GMedicaid
TX00220GMedicaid
0220GMedicare PIN