Provider Demographics
NPI:1417907320
Name:FISHBAUGH, LARRY BRENT (DO)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:BRENT
Last Name:FISHBAUGH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1032 W WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:PAULDING
Mailing Address - State:OH
Mailing Address - Zip Code:45879-1545
Mailing Address - Country:US
Mailing Address - Phone:419-399-2045
Mailing Address - Fax:
Practice Address - Street 1:220 W PERRY ST
Practice Address - Street 2:
Practice Address - City:PAULDING
Practice Address - State:OH
Practice Address - Zip Code:45879-1452
Practice Address - Country:US
Practice Address - Phone:419-399-4771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-001653F207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0056353Medicaid
OHD95232Medicare UPIN
OH0056353Medicaid