Provider Demographics
NPI:1093784951
Name:FISCHBERG, GLENN MARK (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:MARK
Last Name:FISCHBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 LACANADA STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-2592
Mailing Address - Country:US
Mailing Address - Phone:702-731-8115
Mailing Address - Fax:702-784-7844
Practice Address - Street 1:31700 TEMECULA PKWY
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-5896
Practice Address - Country:US
Practice Address - Phone:951-331-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83991207RC0200X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1093784951Medicaid
NV100507939Medicaid
AZ981440Medicaid
CAXPY205010Medicaid
NV1093784951Medicaid
AZ1093784951Medicaid
UT1093784951Medicaid
P00305218Medicare PIN
CAXPY205010Medicaid
AZ1093784951Medicaid
NVCR323ZMedicare PIN
NVV102159Medicare PIN