Provider Demographics
NPI:1255319638
Name:FISHER, CARL ELLIS
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:ELLIS
Last Name:FISHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2544 COURT DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-3450
Mailing Address - Country:US
Mailing Address - Phone:704-867-5356
Mailing Address - Fax:704-867-4990
Practice Address - Street 1:2544 COURT DR
Practice Address - Street 2:SUITE C
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3450
Practice Address - Country:US
Practice Address - Phone:704-867-5356
Practice Address - Fax:704-867-4990
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00-16359208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8932130Medicaid
SCNC2886Medicaid