Provider Demographics
NPI:1952327173
Name:FISHER, SIMON J (MD)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:J
Last Name:FISHER
Suffix:
Gender:M
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:PO BOX 413033
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-3033
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:
Practice Address - Street 1:2195 HARRODSBURG RD STE 125
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3543
Practice Address - Country:US
Practice Address - Phone:859-323-2232
Practice Address - Fax:859-257-1078
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9141045-1205207RE0101X
KYTP463207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO820790183Medicaid
IL$$$$$$$$$Medicaid
MO820790183Medicaid
MO820790183Medicare PIN