Provider Demographics
NPI:1396845269
Name:FISHMAN, MIRIAM (MD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:FISHMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 ENGLE ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2444
Mailing Address - Country:US
Mailing Address - Phone:201-569-5678
Mailing Address - Fax:201-569-6225
Practice Address - Street 1:216 ENGLE ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2444
Practice Address - Country:US
Practice Address - Phone:201-569-5678
Practice Address - Fax:201-569-6225
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04551200207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE70440Medicare UPIN
NJ473137Medicare ID - Type Unspecified