Healthcare Provider Details

I. General information

NPI: 1154873362
Provider Name (Legal Business Name): DR TED Y FISHER A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 G ST
BRAWLEY CA
92227-2544
US

IV. Provider business mailing address

608 G ST
BRAWLEY CA
92227-2568
US

V. Phone/Fax

Practice location:
  • Phone: 760-344-1101
  • Fax:
Mailing address:
  • Phone: 760-344-1102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberA052523
License Number StateCA

VIII. Authorized Official

Name: DR. TED YOSHIO FISHER MD
Title or Position: CEO & PRESIDENT
Credential: MD
Phone: 619-905-1164