Provider Demographics
NPI:1548212368
Name:FISH, MARK DOUGLAS (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DOUGLAS
Last Name:FISH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:12499 UNIVERSITY AVE
Mailing Address - Street 2:STE. 210
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8288
Mailing Address - Country:US
Mailing Address - Phone:515-440-2676
Mailing Address - Fax:515-440-2677
Practice Address - Street 1:12499 UNIVERSITY AVE
Practice Address - Street 2:STE. 210
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8288
Practice Address - Country:US
Practice Address - Phone:515-440-2676
Practice Address - Fax:515-440-2677
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA3790207X00000X
IN02003044A207X00000X, 207XS0114X, 207XX0004X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000480577OtherBCBS
INP00325521OtherRR MEDICARE
IN7305819OtherAETNA
IN4178250001OtherDME
IN075965OtherSIHO
IN2655165OtherUNITED HEALTH CARE
IN075965OtherSIHO
INP00325521OtherRR MEDICARE
IN2655165OtherUNITED HEALTH CARE