Provider Demographics
NPI:1720049968
Name:FISHMAN, LARRY (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:FISHMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 S PARSONS AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5291
Mailing Address - Country:US
Mailing Address - Phone:813-653-2770
Mailing Address - Fax:813-654-6668
Practice Address - Street 1:427 S PARSONS AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5291
Practice Address - Country:US
Practice Address - Phone:813-653-2770
Practice Address - Fax:813-654-6668
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0053007204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048364800Medicaid
FL07138Medicare ID - Type Unspecified
FL048364800Medicaid