Provider Demographics
NPI:1649482274
Name:FISHE, KEITH F (OD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:F
Last Name:FISHE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2283 NORTH DECATUR RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-5423
Mailing Address - Country:US
Mailing Address - Phone:770-314-3756
Mailing Address - Fax:
Practice Address - Street 1:3580 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-2723
Practice Address - Country:US
Practice Address - Phone:404-284-0701
Practice Address - Fax:404-284-0703
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1157T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00528844AMedicaid
GA00528844BMedicaid
GAU26325Medicare UPIN
GA202I412079Medicare PIN