Provider Demographics
NPI:1295899128
Name:FISHER, DIANA L (OD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:FISHER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0549
Mailing Address - Country:US
Mailing Address - Phone:260-569-9550
Mailing Address - Fax:260-569-0760
Practice Address - Street 1:5319 S EMERSON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-1969
Practice Address - Country:US
Practice Address - Phone:317-783-8700
Practice Address - Fax:317-783-5987
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201137280Medicaid
INV04632Medicare UPIN
IN201137280Medicaid
IN894060TMedicare PIN
IN160450034Medicare PIN
IN669220011Medicare PIN