Provider Demographics
NPI:1154462174
Name:FISHMAN, MARK LEWIS (LAC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:LEWIS
Last Name:FISHMAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2035 WESTWOOD BLVD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6332
Mailing Address - Country:US
Mailing Address - Phone:310-849-8110
Mailing Address - Fax:310-454-0188
Practice Address - Street 1:2035 WESTWOOD BLVD
Practice Address - Street 2:SUITE 209
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6332
Practice Address - Country:US
Practice Address - Phone:310-849-8110
Practice Address - Fax:310-454-0188
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAAC6995171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist