Provider Demographics
NPI:1891779195
Name:FISHAUT, JACK MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:MARK
Last Name:FISHAUT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 796
Mailing Address - Street 2:
Mailing Address - City:FRIDAY HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98250-0796
Mailing Address - Country:US
Mailing Address - Phone:360-370-5971
Mailing Address - Fax:360-370-5980
Practice Address - Street 1:235 BLAIR AVE
Practice Address - Street 2:
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250-0796
Practice Address - Country:US
Practice Address - Phone:360-370-5971
Practice Address - Fax:360-370-5980
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00040965208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
361929500OtherPARK NATL L & L
532300004OtherGROUP HEALTH
4952FIOtherREGENCE BLUE SHIELD
912109329OtherUNIFORM
912109329OtherCHPW
912109329OtherPREMERA BLUE CROSS
LABOR AND INDUSTRIESOther0182789
8387367OtherDSHS MEDICAID
912109329OtherFIRST CHOICE
8930937OtherCRIME VICTIMS
8930937OtherCRIME VICTIMS
912109329OtherCHPW