Provider Demographics
NPI:1639338312
Name:GARY M FISHBERG O D PROF CORP
Entity Type:Organization
Organization Name:GARY M FISHBERG O D PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:FISHBERG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:951-788-2020
Mailing Address - Street 1:5225 CANYON CREST DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-6301
Mailing Address - Country:US
Mailing Address - Phone:951-788-2020
Mailing Address - Fax:
Practice Address - Street 1:5225 CANYON CREST DR
Practice Address - Street 2:SUITE 201
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-6301
Practice Address - Country:US
Practice Address - Phone:951-788-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6656T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0066562Medicaid
CA6276031Medicare PIN