Provider Demographics
NPI:1710078944
Name:FISHBACK, ROBERT GLEN (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:GLEN
Last Name:FISHBACK
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 1:1015 N DEMAREE ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4117
Mailing Address - Country:US
Mailing Address - Phone:559-733-1036
Mailing Address - Fax:559-733-1037
Practice Address - Street 1:1015 N DEMAREE ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-4117
Practice Address - Country:US
Practice Address - Phone:559-733-1036
Practice Address - Fax:559-733-1037
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5664152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist