Provider Demographics
NPI:1629151261
Name:FISHER, THOMAS DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:DAVID
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:P.O. BOX 1527
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28359-1527
Mailing Address - Country:US
Mailing Address - Phone:910-738-8222
Mailing Address - Fax:910-671-0846
Practice Address - Street 1:209 WEST 27TH STREET
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3016
Practice Address - Country:US
Practice Address - Phone:910-738-8222
Practice Address - Fax:910-671-0846
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010810142085R0202X
NC2010-000132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4522353Medicaid
MIDD4837OtherMEDICARE RR GROUP PIN
MI310A710590OtherBCBS GROUP PIN
NC5913863Medicaid
NC156P8OtherBLUE CROSS BLUE SHIELD
MIDD4837OtherMEDICARE RR GROUP PIN
MI0E26001018Medicare ID - Type Unspecified
NC2075592Medicare PIN
H92687Medicare UPIN
NC5913863Medicaid
MIP20090002Medicare PIN