Healthcare Provider Details

I. General information

NPI: 1417953043
Provider Name (Legal Business Name): SIDNEY MARK FISHMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 12/04/2024
Certification Date:
Deactivation Date: 04/04/2006
Reactivation Date: 06/28/2006

III. Provider practice location address

40 OCEAN VISTA
NEWPORT BEACH CA
92660
US

IV. Provider business mailing address

40 OCEAN VISTA
NEWPORT BEACH CA
92660
US

V. Phone/Fax

Practice location:
  • Phone: 949-705-8992
  • Fax: 562-596-5703
Mailing address:
  • Phone: 949-705-8992
  • Fax: 562-596-5703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberAF7229455
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberAF7229455
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberAF7229455
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: