Provider Demographics
NPI:1801077466
Name:FISHER, JEFFREY DOUGLAS (IDC)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DOUGLAS
Last Name:FISHER
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 APT A
Mailing Address - Street 2:CUSHMAN AVE
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734
Mailing Address - Country:US
Mailing Address - Phone:808-753-0469
Mailing Address - Fax:
Practice Address - Street 1:2709 APT A
Practice Address - Street 2:CUSHMAN AVE
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734
Practice Address - Country:US
Practice Address - Phone:808-753-0469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman