Provider Demographics
NPI:1780794644
Name:JACK E FISHER DPM INC
Entity type:Organization
Organization Name:JACK E FISHER DPM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:408-842-0281
Mailing Address - Street 1:80 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-5702
Mailing Address - Country:US
Mailing Address - Phone:408-842-0281
Mailing Address - Fax:408-848-4341
Practice Address - Street 1:80 5TH ST
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-5702
Practice Address - Country:US
Practice Address - Phone:408-842-0281
Practice Address - Fax:408-848-4341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1702213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1629072392OtherINDIVIDUAL NPI
CA1780794644OtherGROUP NPI
CAE1702OtherLICENSE
CA1780794644OtherGROUP NPI
CAE1702OtherLICENSE
CAT11034Medicare UPIN
CA000E17020Medicare PIN