Provider Demographics
NPI:1013908599
Name:FISHMAN, LEORA (MD)
Entity type:Individual
Prefix:
First Name:LEORA
Middle Name:
Last Name:FISHMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-1819
Mailing Address - Country:US
Mailing Address - Phone:617-628-2160
Mailing Address - Fax:617-628-8237
Practice Address - Street 1:1020 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-1819
Practice Address - Country:US
Practice Address - Phone:617-628-2160
Practice Address - Fax:617-628-8237
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA50087207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
7684OtherHARVARD PILGRIM HEALTHCAR
MAJ02757OtherBCBS
MA050087OtherTUFTS HEALTH
MA3158152Medicaid
MAJ02757OtherBCBS
B74306Medicare UPIN