Basic Information
Provider Information | |||||||||
NPI: | 1578654968 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FISHMAN | ||||||||
FirstName: | SIMON | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6355 WALKER LANE | ||||||||
Address2: | 313 | ||||||||
City: | ALEXANDRIA | ||||||||
State: | VA | ||||||||
PostalCode: | 22310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7033139111 | ||||||||
FaxNumber: | 7033134945 | ||||||||
Practice Location | |||||||||
Address1: | 6355 WALKER LANE | ||||||||
Address2: | 313 | ||||||||
City: | ALEXANDRIA | ||||||||
State: | VA | ||||||||
PostalCode: | 22310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7033139111 | ||||||||
FaxNumber: | 7033134945 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/28/2006 | ||||||||
LastUpdateDate: | 12/21/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0101225797 | VA | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | J330 0001 | 01 | DC | CF BC BS DC | OTHER | P00148017 | 01 | VA | RAILROAD MEDICARE | OTHER | 102355 | 01 | VA | ANTHEM | OTHER | 2119441 | 01 | VA | ALLIANCE/ MAMSI | OTHER | 518960 | 01 | VA | NCPPO | OTHER | 267731 | 01 | VA | AMERIGROUP | OTHER | 3403215 | 01 | VA | AETNA HMO | OTHER | 010045479 | 05 | VA |   | MEDICAID | 7099103 | 01 | VA | AETNA PPO | OTHER |