Provider Demographics
NPI:1700878949
Name:FISHER, MAHANA S (MD)
Entity Type:Individual
Prefix:DR
First Name:MAHANA
Middle Name:S
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 130
Mailing Address - Street 2:
Mailing Address - City:MONTEZUMA CREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84534
Mailing Address - Country:US
Mailing Address - Phone:435-651-3700
Mailing Address - Fax:435-651-3376
Practice Address - Street 1:804 N 400 W
Practice Address - Street 2:
Practice Address - City:BLANDING
Practice Address - State:UT
Practice Address - Zip Code:84511-3417
Practice Address - Country:US
Practice Address - Phone:435-678-2254
Practice Address - Fax:435-678-2534
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4759456-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD3624Medicaid
UT005575104Medicare ID - Type UnspecifiedBLANDING CLINIC
UT006105012Medicare ID - Type UnspecifiedSJ ER
UT006964005Medicare ID - Type UnspecifiedSJ CLINIC
G72221Medicare UPIN