Provider Demographics
NPI:1508978230
Name:FISHER, MICHAEL THOMAS (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:FISHER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-3821
Mailing Address - Country:US
Mailing Address - Phone:765-488-0216
Mailing Address - Fax:765-488-0654
Practice Address - Street 1:1835 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-3821
Practice Address - Country:US
Practice Address - Phone:765-488-0216
Practice Address - Fax:765-488-0654
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002408A152W00000X
IN18002408B152W00000X
IN18002408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU33417Medicare UPIN
IN7575790001Medicare NSC