Provider Demographics
NPI:1649317264
Name:FISHMAN, MARC JUDAH (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:JUDAH
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 1:3800 FREDERICK AVENUE
Mailing Address - Street 2:NA
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229
Mailing Address - Country:US
Mailing Address - Phone:410-233-1400
Mailing Address - Fax:410-233-5583
Practice Address - Street 1:3800 FREDERICK AVENUE
Practice Address - Street 2:NA
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-3618
Practice Address - Country:US
Practice Address - Phone:410-233-1400
Practice Address - Fax:410-233-5583
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00389132084A0401X, 2084P0800X, 2084P0802X, 2084P0804X
DCMD192272084A0401X, 2084P0800X, 2084P0802X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
BF2501725 XF2501725OtherCONTROLLED SUBSTANCE REG
BF2501725 XF2501725OtherCONTROLLED SUBSTANCE REG