Provider Demographics
NPI:1497748883
Name:FISH, JONATHAN SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SCOTT
Last Name:FISH
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 1:2470 LONGSTONE LN
Mailing Address - Street 2:STE I
Mailing Address - City:MARRIOTTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21104-1523
Mailing Address - Country:US
Mailing Address - Phone:410-910-2300
Mailing Address - Fax:410-910-2310
Practice Address - Street 1:2470 LONGSTONE LN STE I
Practice Address - Street 2:
Practice Address - City:MARRIOTTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21104-1523
Practice Address - Country:US
Practice Address - Phone:410-910-2300
Practice Address - Fax:410-740-9134
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0051860207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCB6100004OtherBC BS
MD769210200Medicaid
G57607Medicare UPIN
MD769210200Medicaid
MD769210200Medicaid