Provider Demographics
NPI:1053360115
Name:FISHER, DANA JUSTINE (DPM)
Entity type:Individual
Prefix:DR
First Name:DANA
Middle Name:JUSTINE
Last Name:FISHER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 EXPRESS LN
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118
Mailing Address - Country:US
Mailing Address - Phone:803-536-2100
Mailing Address - Fax:803-536-4399
Practice Address - Street 1:135 EXPRESS LN
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118
Practice Address - Country:US
Practice Address - Phone:803-536-2100
Practice Address - Fax:803-536-4399
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC00567213ES0131X
GA000939213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5991930001Medicare NSC
SCU96190Medicare UPIN
SC5405470001Medicare NSC