Provider Demographics
NPI:1275576712
Name:FISHER, MARK ROWELL (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROWELL
Last Name:FISHER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5455 MURRELL ROAD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32955-6615
Mailing Address - Country:US
Mailing Address - Phone:321-636-1972
Mailing Address - Fax:321-636-1507
Practice Address - Street 1:5455 MURRELL RD
Practice Address - Street 2:SUITE 107
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-6615
Practice Address - Country:US
Practice Address - Phone:321-636-1972
Practice Address - Fax:321-636-1507
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 1739152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19829OtherBCBS OF FL
FL078956900Medicaid
FL410038561Medicare PIN
FL19829YMedicare PIN
FL0539980004Medicare NSC
FL0539980005Medicare NSC
FL0539980006Medicare NSC
FLT85231Medicare UPIN
FL19829ZMedicare PIN
FL078956900Medicaid
FL19829OtherBCBS OF FL
FL0539980001Medicare NSC