Healthcare Provider Details

I. General information

NPI: 1205828985
Provider Name (Legal Business Name): MICHAEL J DISHER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9604 COLDWATER RD STE 103
FORT WAYNE IN
46825-2096
US

IV. Provider business mailing address

9604 COLDWATER RD STE 103
FORT WAYNE IN
46825-2096
US

V. Phone/Fax

Practice location:
  • Phone: 260-387-5820
  • Fax:
Mailing address:
  • Phone: 260-387-5820
  • Fax: 855-828-7823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number01044624A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number35 078705
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number01044624A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: