Provider Demographics
NPI:1205970142
Name:FISHMAN, LOREN M (MD)
Entity type:Individual
Prefix:
First Name:LOREN
Middle Name:M
Last Name:FISHMAN
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:PO BOX 1357
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11709-0357
Mailing Address - Country:US
Mailing Address - Phone:516-794-4161
Mailing Address - Fax:516-794-9568
Practice Address - Street 1:1009 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0936
Practice Address - Country:US
Practice Address - Phone:212-472-0077
Practice Address - Fax:212-472-4127
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150259208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
C06694Medicare UPIN
NY20D131L061Medicare PIN
NY02708GMedicare PIN