Provider Demographics
NPI:1104855535
Name:FISHMAN, CRAIG (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:
Last Name:FISHMAN
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 1:640 S LAKE ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5927
Mailing Address - Country:US
Mailing Address - Phone:352-360-2301
Mailing Address - Fax:352-315-7631
Practice Address - Street 1:640 S LAKE ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5927
Practice Address - Country:US
Practice Address - Phone:352-360-2301
Practice Address - Fax:352-315-7631
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0070736207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL180025336OtherRAILROAD MEDICARE
31954OtherBCBS
FL250513400Medicaid
FL1104855535Medicare PIN
FL0583930001Medicare NSC
FL1700960507Medicare PIN
FL250513400Medicaid
31954ZMedicare ID - Type Unspecified