Healthcare Provider Details

I. General information

NPI: 1457242430
Provider Name (Legal Business Name): IAN FISCHMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2025
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LAKESIDE MEDICAL GROUP HIDALGO 148B
CHAPALA JALSICO
45922
MX

IV. Provider business mailing address

5830 E 2ND ST
CASPER WY
82609-4308
US

V. Phone/Fax

Practice location:
  • Phone: 888-449-7799
  • Fax:
Mailing address:
  • Phone: 888-449-7799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberCEDULA
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: