Provider Demographics
NPI:1912972423
Name:FISH, KENNETH J SR (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:FISH
Suffix:SR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BRIDGE STREET
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619
Mailing Address - Country:US
Mailing Address - Phone:315-493-7334
Mailing Address - Fax:315-493-1811
Practice Address - Street 1:3 BRIDGE STREET
Practice Address - Street 2:SUITE 3
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619
Practice Address - Country:US
Practice Address - Phone:315-493-7334
Practice Address - Fax:315-493-1811
Is Sole Proprietor?:No
Enumeration Date:2006-02-18
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY172139207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY196957660OtherSTATE ISSUED ID NUMBER
NY01079116Medicaid
NY01079116Medicaid
52744CMedicare ID - Type Unspecified