Provider Demographics
NPI:1356529028
Name:FISHER, MARK BRADLEY (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:BRADLEY
Last Name:FISHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1925 MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3128
Mailing Address - Country:US
Mailing Address - Phone:720-718-8305
Mailing Address - Fax:303-485-3377
Practice Address - Street 1:1925 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3128
Practice Address - Country:US
Practice Address - Phone:720-718-8305
Practice Address - Fax:303-485-3377
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036122470208800000X
CO054743208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036122470Medicaid
CO025542OtherKAISER COMMERCIAL NUMBER
CO61402516Medicaid
CO397584YK5YMedicare PIN