Healthcare Provider Details

I. General information

NPI: 1245235761
Provider Name (Legal Business Name): DOUGLAS FISHER P.A.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 HAMPTON RD
SOUTHAMPTON NY
11968-4923
US

IV. Provider business mailing address

PO BOX 273
EAST MARION NY
11939
US

V. Phone/Fax

Practice location:
  • Phone: 631-287-8600
  • Fax: 631-204-1585
Mailing address:
  • Phone: 631-287-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00256
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number23-013281
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: