Healthcare Provider Details

I. General information

NPI: 1003814419
Provider Name (Legal Business Name): FRED NMN FISCH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/09/2005
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 S COUNTRY CLUB DR STE 102
MESA AZ
85210-6042
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 480-834-6367
  • Fax: 480-834-7277
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-000618
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: