Provider Demographics
NPI:1386677128
Name:FISCHER, LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:
Last Name:FISCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1644
Mailing Address - Country:US
Mailing Address - Phone:618-939-5511
Mailing Address - Fax:
Practice Address - Street 1:628 E 4TH ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1644
Practice Address - Country:US
Practice Address - Phone:618-939-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102900207Q00000X
IL036.077712207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOC43376Medicare UPIN