Provider Demographics
NPI:1891969606
Name:FISHER, JONATHAN DONALD (DPM)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DONALD
Last Name:FISHER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30544 HIGHWAY 200
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852-5005
Mailing Address - Country:US
Mailing Address - Phone:208-265-9817
Mailing Address - Fax:208-265-4533
Practice Address - Street 1:30544 HIGHWAY 200
Practice Address - Street 2:SUITE 102
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-5005
Practice Address - Country:US
Practice Address - Phone:208-265-9817
Practice Address - Fax:208-265-4533
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-198213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP2448OtherBLUE CROSS
ID808011000Medicaid
ID1100300OtherMEDICARE
ID000010167109OtherREGENCE BLUE SHIELD
IDP00638389OtherRAILROAD MEDICARE