Provider Demographics
NPI:1891837852
Name:FISHBERG, GARY MARTIN (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:MARTIN
Last Name:FISHBERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 CANYON CREST DR STE 201
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-6323
Mailing Address - Country:US
Mailing Address - Phone:951-788-2020
Mailing Address - Fax:951-684-2020
Practice Address - Street 1:5225 CANYON CREST DR STE 201
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-6323
Practice Address - Country:US
Practice Address - Phone:951-788-2020
Practice Address - Fax:951-684-2020
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6656152W00000X
CA6656T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0066562Medicaid
CA6276031Medicare UPIN