Provider Demographics
NPI:1780624213
Name:FISKE, WILLIAM WYMAN (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM WYMAN
Middle Name:
Last Name:FISKE
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 1:134 ANSEL HALLET RD
Mailing Address - Street 2:
Mailing Address - City:W YARMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02673-2582
Mailing Address - Country:US
Mailing Address - Phone:508-771-9779
Mailing Address - Fax:
Practice Address - Street 1:134 ANSEL HALLET RD
Practice Address - Street 2:
Practice Address - City:W YARMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02673-2582
Practice Address - Country:US
Practice Address - Phone:508-771-9779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA74240207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP00429633OtherRR MEDICARE
MA110095135AMedicaid
MAJ11263OtherBLUE CROSS BLUE SHIELD
MAE88465Medicare UPIN
MAJ11263Medicare PIN