Organization
THOMAS A FISK MD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DIRENDIA SHACKELFORD (MANAGED CARE SPECIALIST)
(800) 654-0889
Entity
Organization
Contact information
Practice address
NEW INTERLOCHEN PEDIATRICS, 846 LAKE HOWELL RD, MAITLAND, FL 32751
(407) 767-2477
(407) 834-9822
Mailing address
NEW INTERLOCHEN PEDIATRICS, 846 LAKE HOWELL RD, MAITLAND, FL 32751
Taxonomy
Speciality
Code
Description
License number
State
332900000X
Non-Pharmacy Dispensing Site
Primary
ME61050
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1084312
OTHER ID NUMBER-COMMERCIAL NUMBER
—
05
—
58690100
—
FL
Enumeration date
06/20/2006
Last updated
08/22/2020
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