Provider Demographics
NPI:1053614073
Name:FISHER, MARK ALAN (LMT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:FISHER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 NE 17TH CT
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33305-3127
Mailing Address - Country:US
Mailing Address - Phone:954-463-6791
Mailing Address - Fax:954-463-0830
Practice Address - Street 1:916 NE 17TH CT
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33305-3127
Practice Address - Country:US
Practice Address - Phone:954-463-6791
Practice Address - Fax:954-463-0830
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA16739225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL676363400Medicare PIN
FL225700000XMedicare PIN