Provider Demographics
NPI:1689719361
Name:FISCHER, JOHN A (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:FISCHER
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 1:247 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DURYEA
Mailing Address - State:PA
Mailing Address - Zip Code:18642
Mailing Address - Country:US
Mailing Address - Phone:570-457-9770
Mailing Address - Fax:570-451-6332
Practice Address - Street 1:247 MAIN ST
Practice Address - Street 2:
Practice Address - City:DURYEA
Practice Address - State:PA
Practice Address - Zip Code:18642
Practice Address - Country:US
Practice Address - Phone:570-457-9770
Practice Address - Fax:570-451-6332
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG00758152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA15-01410308Medicaid
PAU02754Medicare UPIN
PA15-01410308Medicaid