Healthcare Provider Details

I. General information

NPI: 1114213451
Provider Name (Legal Business Name): TYLER J FISHER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2011
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 PLEASANT ST
DES MOINES IA
50309-1406
US

IV. Provider business mailing address

1200 PLEASANT ST
DES MOINES IA
50309-1406
US

V. Phone/Fax

Practice location:
  • Phone: 515-241-6611
  • Fax:
Mailing address:
  • Phone: 515-241-6611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number2014008797
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number04-40003
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberMD-47856
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: