Provider Demographics
NPI:1710920467
Name:FISHER, TIMOTHY MARK (DO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MARK
Last Name:FISHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 VO TECH DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MC MINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-1329
Mailing Address - Country:US
Mailing Address - Phone:931-473-4441
Mailing Address - Fax:931-473-5031
Practice Address - Street 1:140 VO TECH DR
Practice Address - Street 2:SUITE 6
Practice Address - City:MC MINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1329
Practice Address - Country:US
Practice Address - Phone:931-473-4441
Practice Address - Fax:931-473-5031
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO0000000851207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3374306Medicaid
TN51818OtherBLUE CROSS BLUE SHIELD
TN51818OtherBLUE CROSS BLUE SHIELD
TN3374306Medicare ID - Type Unspecified