Provider Demographics
NPI:1871503102
Name:FISHER, MARY LEAH (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEAH
Last Name:FISHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 121ST ST APT A
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-8543
Mailing Address - Country:US
Mailing Address - Phone:360-969-6775
Mailing Address - Fax:
Practice Address - Street 1:3601 4TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-0002
Practice Address - Country:US
Practice Address - Phone:806-317-0016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60126645208600000X
TXU51882086H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086H0002XAllopathic & Osteopathic PhysiciansSurgeryHospice and Palliative Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148564001Medicaid
ARG90033Medicare UPIN
AR5M228Medicare ID - Type Unspecified