Provider Demographics
NPI:1639106784
Name:FISHER, MICHAEL RAND (O D)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAND
Last Name:FISHER
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 10TH ST
Mailing Address - Street 2:P. O. BOX 457
Mailing Address - City:WINDOM
Mailing Address - State:MN
Mailing Address - Zip Code:56101-1411
Mailing Address - Country:US
Mailing Address - Phone:507-831-3478
Mailing Address - Fax:507-831-3479
Practice Address - Street 1:230 10TH ST
Practice Address - Street 2:
Practice Address - City:WINDOM
Practice Address - State:MN
Practice Address - Zip Code:56101-0457
Practice Address - Country:US
Practice Address - Phone:507-831-3478
Practice Address - Fax:507-831-3479
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1482152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN293823500Medicaid
MNT65512Medicare UPIN
MN293823500Medicaid
IN0174720001Medicare NSC
MN419000445Medicare PIN