Healthcare Provider Details

I. General information

NPI: 1659512762
Provider Name (Legal Business Name): EDWARD NEIL FISHMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2009
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5375 S FORT APACHE RD
LAS VEGAS NV
89148-7623
US

IV. Provider business mailing address

PO BOX 370854
LAS VEGAS NV
89137-0854
US

V. Phone/Fax

Practice location:
  • Phone: 702-253-6888
  • Fax:
Mailing address:
  • Phone: 702-253-6888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberCA-20A6414
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberOS-007153-L
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number517
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: