Provider Demographics
NPI:1386669190
Name:FISK, HARRIS RONALD (MD PHD)
Entity Type:Individual
Prefix:
First Name:HARRIS
Middle Name:RONALD
Last Name:FISK
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8631 W 3RD ST
Mailing Address - Street 2:SUITE 620-E
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5901
Mailing Address - Country:US
Mailing Address - Phone:310-657-0942
Mailing Address - Fax:310-652-2499
Practice Address - Street 1:8631 W 3RD ST
Practice Address - Street 2:SUITE 620E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5901
Practice Address - Country:US
Practice Address - Phone:310-657-0942
Practice Address - Fax:310-652-2499
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG203002084N0400X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHG20300AMedicaid
CAHG20300AMedicaid
CAWG20300AMedicare PIN