Healthcare Provider Details

I. General information

NPI: 1306846621
Provider Name (Legal Business Name): SHAUL FISHMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 ROUTE 111
HAUPPAUGE NY
11788-4370
US

IV. Provider business mailing address

1771 E 29TH ST
BROOKLYN NY
11229-2516
US

V. Phone/Fax

Practice location:
  • Phone: 631-265-9645
  • Fax: 631-265-5589
Mailing address:
  • Phone: 718-375-7607
  • Fax: 718-375-9080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number178629
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: