Provider Demographics
NPI:1912014002
Name:FISHMAN, PAUL JORDAN (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JORDAN
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 1:3885 UPHAM ST
Mailing Address - Street 2:100
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4880
Mailing Address - Country:US
Mailing Address - Phone:303-742-0108
Mailing Address - Fax:303-742-0690
Practice Address - Street 1:3885 UPHAM ST
Practice Address - Street 2:100
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4880
Practice Address - Country:US
Practice Address - Phone:303-742-0108
Practice Address - Fax:303-742-0690
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17709207Q00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO110086492OtherRRW MEDICARE
CO01177096Medicaid
CO110086492OtherRRW MEDICARE
CO01177096Medicaid