Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RI0011X | Interventional Cardiology | N6731 | AR |
NPI | 1053375857 |
---|---|
Provider Name | Dr. Ted J Fish |
First Address | Fayetteville, AR 72703-4007 |
Second Address | Fayetteville, AR 72703-4007 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/04/2006 |
Last Update Date | 28/06/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100177890A | (05) | OK |
106458001 | (05) | AR |
122040000 | QUALCHOICE (01) | AR |
1670493 | UNITED HEALTHCARE (01) | AR |
204813208 | (05) | MO |
4574734 | AETNA (01) | AR |
A012 | CHAMPUS (01) | AR |
AF9625964 | DEA (01) | AR |
D04531 | (02) | AR |
N6731 | STATE LICENSE (01) | AR |