Provider Demographics
NPI:1659512762
Name:FISHMAN, EDWARD NEIL (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:NEIL
Last Name:FISHMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 370854
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89137-0854
Mailing Address - Country:US
Mailing Address - Phone:702-253-6888
Mailing Address - Fax:
Practice Address - Street 1:5375 S FORT APACHE RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-7623
Practice Address - Country:US
Practice Address - Phone:702-253-6888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-19
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA-20A6414207QA0505X
PAOS-007153-L207QA0505X
NV517207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVE80793Medicare UPIN
31449Medicare PIN