Provider Demographics
NPI:1306038153
Name:FISHER, BENJAMIN C (OD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:C
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 1:200 ACADEMY DR
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25271-1157
Mailing Address - Country:US
Mailing Address - Phone:304-373-1256
Mailing Address - Fax:
Practice Address - Street 1:200 ACADEMY DR
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:WV
Practice Address - Zip Code:25271-1157
Practice Address - Country:US
Practice Address - Phone:304-373-1256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-15
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1043-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV10020281OtherMEDICARE PTAN