Provider Demographics
NPI:1184610784
Name:FISHER, MARY V (OD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:V
Last Name:FISHER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4701
Mailing Address - Country:US
Mailing Address - Phone:602-955-1000
Mailing Address - Fax:602-508-4830
Practice Address - Street 1:1626 N LITCHFIELD RD STE 110
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-1399
Practice Address - Country:US
Practice Address - Phone:602-955-1000
Practice Address - Fax:602-508-4830
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0808152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0808OtherSTATE LICENSE
MIN93090001Medicare ID - Type UnspecifiedMEMBER NUMBER
MI900F111050OtherBC BS OF MICHIGAN
MI4606266Medicaid