Healthcare Provider Details

I. General information

NPI: 1124019187
Provider Name (Legal Business Name): LARRY A. FISH M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 E HIGH ST
SPRINGFIELD OH
45505-1371
US

IV. Provider business mailing address

2330 E HIGH ST
SPRINGFIELD OH
45505-1371
US

V. Phone/Fax

Practice location:
  • Phone: 937-324-3937
  • Fax: 937-324-8943
Mailing address:
  • Phone: 937-324-3937
  • Fax: 937-324-8943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35-06-2993
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: