Provider Demographics
NPI:1760598973
Name:FISH, DEIDRE M (MD)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:M
Last Name:FISH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEIDRE
Other - Middle Name:
Other - Last Name:MICHELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1080 FIRST COLONIAL RD
Mailing Address - Street 2:STE 300
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2406
Mailing Address - Country:US
Mailing Address - Phone:757-481-7222
Mailing Address - Fax:757-390-2935
Practice Address - Street 1:1080 FIRST COLONIAL RD
Practice Address - Street 2:STE 300
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2406
Practice Address - Country:US
Practice Address - Phone:757-481-7222
Practice Address - Fax:757-390-2935
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101261053207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276509800Medicaid
FLAB239ZMedicare PIN