Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | ME0053007 | FL |
NPI | 1720049968 |
---|---|
Provider Name | Larry Fishman |
First Address | Brandon, FL 33511-5291 |
Second Address | Brandon, FL 33511-5291 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/03/2006 |
Last Update Date | 23/02/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
048364800 | (05) | FL |
D51861 | (02) | FL |