Provider Demographics
NPI:1740375336
Name:FISHER, ROBERT JEREMY JR (PT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JEREMY
Last Name:FISHER
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33845-0699
Mailing Address - Country:US
Mailing Address - Phone:863-206-2854
Mailing Address - Fax:863-422-6233
Practice Address - Street 1:8316 WEST LAKE MARION ROAD
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844
Practice Address - Country:US
Practice Address - Phone:863-206-2854
Practice Address - Fax:863-422-6233
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2015-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT-0002429225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY2044OtherBCBS OF FLORIDA
FL14929800Medicaid
FLFY601AMedicare PIN