Basic Information
| Provider Information | |||||||||
| NPI: | 1508853458 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISKE | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 DIAMOND HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERKELEY HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079222104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082734300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 573 SOUTH AVE EAST | ||||||||
| Address2: | BUILDING A | ||||||||
| City: | CRANFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9086034200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2005 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25MA07851100 | NJ | N | Other Service Providers | Specialist | 208800000X | 25MA07851100 | NJ | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0077984 | 05 | NJ | MEDICAID |