Healthcare Provider Details

I. General information

NPI: 1912962168
Provider Name (Legal Business Name): DOUGLAS S FISHMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

147 MILK ST PROVIDER ENROLLMENT - 9TH FLOOR
BOSTON MA
02109-4806
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-7953
  • Fax:
Mailing address:
  • Phone: 617-559-8053
  • Fax: 617-421-3487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number220952
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberM5159
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number220952
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: