Provider Demographics
NPI:1497856348
Name:FISHMAN, FRED LEON
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:LEON
Last Name:FISHMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1903
Mailing Address - Country:US
Mailing Address - Phone:312-372-6383
Mailing Address - Fax:312-372-2057
Practice Address - Street 1:111 N WABASH AVE
Practice Address - Street 2:STE 910
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1903
Practice Address - Country:US
Practice Address - Phone:312-372-6383
Practice Address - Fax:312-372-2057
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3641080207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC41887Medicare UPIN