Provider Demographics
NPI:1528031838
Name:FISH, GARRY D (OD)
Entity Type:Individual
Prefix:DR
First Name:GARRY
Middle Name:D
Last Name:FISH
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 1:444 UNION ST
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-2741
Mailing Address - Country:US
Mailing Address - Phone:530-527-8777
Mailing Address - Fax:
Practice Address - Street 1:444 UNION ST
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-2741
Practice Address - Country:US
Practice Address - Phone:530-527-8777
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5144152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0051440Medicaid
CASD0051440Medicaid
CAT09883Medicare UPIN