Provider Demographics
NPI:1184626384
Name:FISHBEIN, GARY J (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:J
Last Name:FISHBEIN
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 1:3170 KETTERING BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:2350 MIAMI VALLEY DR STE 310
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4778
Practice Address - Country:US
Practice Address - Phone:937-277-4274
Practice Address - Fax:937-277-8476
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-5086207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0920374Medicaid
OH0920374Medicaid
OHH053030Medicare PIN
OH0920374Medicaid