Healthcare Provider Details

I. General information

NPI: 1467900829
Provider Name (Legal Business Name): MICAYLA FISHER - IVES O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 SAINT MICHAELS DR BLDG A
SANTA FE NM
87505-7620
US

IV. Provider business mailing address

125 W WATER ST
SANTA FE NM
87501-2136
US

V. Phone/Fax

Practice location:
  • Phone: 505-944-4442
  • Fax: 505-954-4448
Mailing address:
  • Phone: 505-988-4442
  • Fax: 505-273-7944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number682
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: