Basic Information
Provider Information
NPI: 1003015553
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FISHMAN
FirstName: MICHAEL
MiddleName: SCOT
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 19020 33RD AVE W
Address2: SUITE 210
City: LYNNWOOD
State: WA
PostalCode: 980364746
CountryCode: US
TelephoneNumber: 4255631500
FaxNumber: 4255631374
Practice Location
Address1: 19020 33RD AVE W
Address2: SUITE 210
City: LYNNWOOD
State: WA
PostalCode: 980364746
CountryCode: US
TelephoneNumber: 4255631500
FaxNumber: 4255631374
Other Information
ProviderEnumerationDate: 07/15/2007
LastUpdateDate: 02/04/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000XMD00029650WAN Other Service ProvidersSpecialist 
2085R0202XMD00029650WAN Allopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
2085R0204XMD00029650WAY Allopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology

ID Information
IDTypeStateIssuerDescription
815113605WA MEDICAID
25747501WALNI PROVIDER IDOTHER


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