Healthcare Provider Details

I. General information

NPI: 1831138304
Provider Name (Legal Business Name): GARY S FISHMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 MEMORIAL MEDICAL PKWY STE 208
DAYTONA BEACH FL
32117-5169
US

IV. Provider business mailing address

PO BOX 947381
ATLANTA GA
30394-7381
US

V. Phone/Fax

Practice location:
  • Phone: 386-231-3593
  • Fax: 386-231-3595
Mailing address:
  • Phone: 386-671-4519
  • Fax: 386-672-9904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number143907
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME158843
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: