Provider Demographics
NPI:1841233400
Name:FISH, JOHN RUSSELL (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RUSSELL
Last Name:FISH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:133 LITTLE CONESTOGA RD
Practice Address - Street 2:
Practice Address - City:CHESTER SPRINGS
Practice Address - State:PA
Practice Address - Zip Code:19425-9562
Practice Address - Country:US
Practice Address - Phone:610-458-9800
Practice Address - Fax:610-458-9806
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG-000898152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA39D2059303OtherCLIA
PAU02249Medicare UPIN