Provider Demographics
NPI:1588669691
Name:FISHER, JEFFREY JAMES (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JAMES
Last Name:FISHER
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 1:1811 HIGHWAY 287 N
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-7571
Mailing Address - Country:US
Mailing Address - Phone:817-473-3979
Mailing Address - Fax:682-518-8919
Practice Address - Street 1:1811 HIGHWAY 287 N
Practice Address - Street 2:STE 150
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-7595
Practice Address - Country:US
Practice Address - Phone:817-473-3979
Practice Address - Fax:682-518-8919
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0073207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8D3603OtherPTAN
8D3603OtherPTAN
TX8D3603Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER