Provider Demographics
NPI:1417165614
Name:FISHBANE GORDON, MEREDITH LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:LEIGH
Last Name:FISHBANE GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:LEIGH
Other - Last Name:FISHBANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1130 S SCOTT BLVD
Mailing Address - Street 2:UICMS SOUTHEAST CLINIC - GENERAL PEDIATRICS
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-2907
Mailing Address - Country:US
Mailing Address - Phone:319-467-6789
Mailing Address - Fax:
Practice Address - Street 1:1130 S SCOTT BLVD
Practice Address - Street 2:UICMS SOUTHEAST CLINIC - GENERAL PEDIATRICS
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-2907
Practice Address - Country:US
Practice Address - Phone:319-467-6789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-19
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA231765208000000X
PAMD429411208000000X
IAMD-41814208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics