Provider Demographics
NPI:1194825752
Name:FISHMAN, CHARLES B (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:B
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 1:1551 BISHOP ST
Mailing Address - Street 2:SUITE 410
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4635
Mailing Address - Country:US
Mailing Address - Phone:805-541-4180
Mailing Address - Fax:805-541-2542
Practice Address - Street 1:1551 BISHOP ST
Practice Address - Street 2:SUITE 410
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4635
Practice Address - Country:US
Practice Address - Phone:805-541-4180
Practice Address - Fax:805-541-2542
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC 31365207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWC31365AOtherPPIN #
CAW18438OtherMEDICARE GROUP #
CAA34547Medicare UPIN