Provider Demographics
NPI:1629026380
Name:FISHERKELLER, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:FISHERKELLER
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 1:90 QUARRY ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-1225
Mailing Address - Country:US
Mailing Address - Phone:860-456-2898
Mailing Address - Fax:860-456-3078
Practice Address - Street 1:90 QUARRY ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-1225
Practice Address - Country:US
Practice Address - Phone:860-456-2898
Practice Address - Fax:860-456-3078
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT021796207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001217967Medicaid
CTD77032Medicare UPIN
CT001217967Medicaid