Provider Demographics
NPI:1457242430
Name:FISCHMAN, IAN (MD)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:FISCHMAN
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 1:5830 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4308
Mailing Address - Country:US
Mailing Address - Phone:888-449-7799
Mailing Address - Fax:
Practice Address - Street 1:LAKESIDE MEDICAL GROUP
Practice Address - Street 2:HIDALGO 148B
Practice Address - City:CHAPALA
Practice Address - State:JALSICO
Practice Address - Zip Code:45922
Practice Address - Country:MX
Practice Address - Phone:888-449-7799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-09
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACEDULA208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice