Basic Information
| Provider Information | |||||||||
| NPI: | 1649482274 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FISHE | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2283 NORTH DECATUR RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300305423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703143756 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3580 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300322723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042840701 | ||||||||
| FaxNumber: | 4042840703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 10/06/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1157T | GA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 00528844A | 05 | GA | MEDICAID | 00528844B | 05 | GA | MEDICAID |