Provider Demographics
NPI:1124157516
Name:FISH, KENNETH JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOHN
Last Name:FISH
Suffix:
Gender:M
Credentials:DC
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 2004
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-2004
Mailing Address - Country:US
Mailing Address - Phone:301-519-1881
Mailing Address - Fax:301-519-1131
Practice Address - Street 1:937 RUSSELL AVE STE B
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3280
Practice Address - Country:US
Practice Address - Phone:301-519-1881
Practice Address - Fax:301-519-1131
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01987111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU98567Medicare UPIN