Provider Demographics
NPI:1467900829
Name:FISHER - IVES, MICAYLA (OD)
Entity Type:Individual
Prefix:MRS
First Name:MICAYLA
Middle Name:
Last Name:FISHER - IVES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 W WATER ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2136
Mailing Address - Country:US
Mailing Address - Phone:505-988-4442
Mailing Address - Fax:505-273-7944
Practice Address - Street 1:444 SAINT MICHAELS DR
Practice Address - Street 2:BLDG A
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7620
Practice Address - Country:US
Practice Address - Phone:505-944-4442
Practice Address - Fax:505-954-4448
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM682152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1467900829OtherNPI