=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083933618
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY FISHMAN DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2010
-----------------------------------------------------
Last Update Date | 06/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 PARKVIEW DR STE 102
-----------------------------------------------------
City | TROPHY CLUB
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76262-4204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-667-4514
-----------------------------------------------------
Fax | 469-620-7558
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 PARKVIEW DR STE 102
-----------------------------------------------------
City | TROPHY CLUB
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76262-4204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-527-6537
-----------------------------------------------------
Fax | 469-620-7558
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 006554
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 692183
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------