Provider Demographics
NPI:1861576845
Name:FISHER, SCOTT W (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:W
Last Name:FISHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3298 MONTECITO MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-1849
Mailing Address - Country:US
Mailing Address - Phone:707-217-3179
Mailing Address - Fax:
Practice Address - Street 1:3298 MONTECITO MEADOW DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-1849
Practice Address - Country:US
Practice Address - Phone:707-217-3179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41278208000000X
MA254926208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G412780Medicaid
CA00G412780Medicaid