Provider Demographics
NPI:1578654968
Name:FISHMAN, SIMON (MD)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:
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 1:6355 WALKER LANE
Mailing Address - Street 2:313
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310
Mailing Address - Country:US
Mailing Address - Phone:703-313-9111
Mailing Address - Fax:703-313-4945
Practice Address - Street 1:6355 WALKER LANE
Practice Address - Street 2:313
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310
Practice Address - Country:US
Practice Address - Phone:703-313-9111
Practice Address - Fax:703-313-4945
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101225797174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCJ330 0001OtherCF BC BS DC
VAP00148017OtherRAILROAD MEDICARE
VA102355OtherANTHEM
VA2119441OtherALLIANCE/ MAMSI
VA518960OtherNCPPO
VA267731OtherAMERIGROUP
VA3403215OtherAETNA HMO
VA010045479Medicaid
VA7099103OtherAETNA PPO
DCG01414Medicare ID - Type Unspecified
VA7099103OtherAETNA PPO