Provider Demographics
NPI:1467410381
Name:FISHBEIN, VITALY (MD)
Entity Type:Individual
Prefix:MR
First Name:VITALY
Middle Name:
Last Name:FISHBEIN
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 1:401 PLEASANT VALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2935
Mailing Address - Country:US
Mailing Address - Phone:973-736-1112
Mailing Address - Fax:973-736-5590
Practice Address - Street 1:401 PLEASANT VALLEY WAY
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2935
Practice Address - Country:US
Practice Address - Phone:973-736-1112
Practice Address - Fax:973-736-5590
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05902900174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6000908Medicaid
NJF00153Medicare UPIN
NJ6000908Medicaid