Healthcare Provider Details

I. General information

NPI: 1417907320
Provider Name (Legal Business Name): LARRY BRENT FISHBAUGH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 01/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W PERRY ST
PAULDING OH
45879-1452
US

IV. Provider business mailing address

1032 W WAYNE ST
PAULDING OH
45879-1545
US

V. Phone/Fax

Practice location:
  • Phone: 419-399-4771
  • Fax:
Mailing address:
  • Phone: 419-399-2045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34-001653F
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: