Healthcare Provider Details

I. General information

NPI: 1639338312
Provider Name (Legal Business Name): GARY M FISHBERG O D PROF CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 03/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 CANYON CREST DR SUITE 201
RIVERSIDE CA
92507-6301
US

IV. Provider business mailing address

5225 CANYON CREST DR SUITE 201
RIVERSIDE CA
92507-6301
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-2020
  • Fax:
Mailing address:
  • Phone: 951-788-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number6656T
License Number StateCA

VIII. Authorized Official

Name: DR. GARY M FISHBERG
Title or Position: OPTOMETRIST/OWNER
Credential: O.D.
Phone: 951-788-2020