Healthcare Provider Details

I. General information

NPI: 1013908599
Provider Name (Legal Business Name): LEORA FISHMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 BROADWAY
SOMERVILLE MA
02144-1819
US

IV. Provider business mailing address

1020 BROADWAY
SOMERVILLE MA
02144-1819
US

V. Phone/Fax

Practice location:
  • Phone: 617-628-2160
  • Fax: 617-628-8237
Mailing address:
  • Phone: 617-628-2160
  • Fax: 617-628-8237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number50087
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: