Healthcare Provider Details

I. General information

NPI: 1629072392
Provider Name (Legal Business Name): JACK ELLIOTT FISHER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8O 5TH ST
GILROY CA
95020-5748
US

IV. Provider business mailing address

8O 5TH ST
GILROY CA
95020-5748
US

V. Phone/Fax

Practice location:
  • Phone: 408-842-0281
  • Fax: 408-848-4341
Mailing address:
  • Phone: 408-842-0281
  • Fax: 408-848-4341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberE1702
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE1702
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: