Provider Demographics
NPI:1437131364
Name:FISHER, GARY W (OD PC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:W
Last Name:FISHER
Suffix:
Gender:M
Credentials:OD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W 1ST ST
Mailing Address - Street 2:PO BOX 228
Mailing Address - City:MONTICELLO
Mailing Address - State:IA
Mailing Address - Zip Code:52310-1519
Mailing Address - Country:US
Mailing Address - Phone:319-465-5114
Mailing Address - Fax:319-465-5523
Practice Address - Street 1:108 W 1ST ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IA
Practice Address - Zip Code:52310-1519
Practice Address - Country:US
Practice Address - Phone:319-465-5114
Practice Address - Fax:319-465-5523
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01615152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0128033Medicaid
IA0296620001Medicare NSC
IAT00803Medicare UPIN
IA12803Medicare PIN