Healthcare Provider Details

I. General information

NPI: 1861576845
Provider Name (Legal Business Name): SCOTT W. FISHER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3298 MONTECITO MEADOW DR
SANTA ROSA CA
95404-1849
US

IV. Provider business mailing address

3298 MONTECITO MEADOW DR
SANTA ROSA CA
95404-1849
US

V. Phone/Fax

Practice location:
  • Phone: 707-217-3179
  • Fax:
Mailing address:
  • Phone: 707-217-3179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG41278
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number254926
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: