Provider Demographics
NPI:1003077322
Name:FENSTERSZAUB, SIMON (DO)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:
Last Name:FENSTERSZAUB
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 SKILLMAN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-1218
Mailing Address - Country:US
Mailing Address - Phone:718-964-6161
Mailing Address - Fax:
Practice Address - Street 1:432 BEDFORD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-6588
Practice Address - Country:US
Practice Address - Phone:718-964-6161
Practice Address - Fax:718-387-9222
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249846207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03157917Medicaid