Provider Demographics
NPI:1083704811
Name:HAKSHOURI, SHIMON R (MD)
Entity Type:Individual
Prefix:
First Name:SHIMON
Middle Name:R
Last Name:HAKSHOURI
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 1:39 TANNERS RD
Mailing Address - Street 2:
Mailing Address - City:LAKE SUCCESS
Mailing Address - State:NY
Mailing Address - Zip Code:11020-1628
Mailing Address - Country:US
Mailing Address - Phone:917-816-2722
Mailing Address - Fax:
Practice Address - Street 1:10201 66TH RD
Practice Address - Street 2:FOREST HILLS HOSPITAL, DEPT. OF MEDICINE
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-2029
Practice Address - Country:US
Practice Address - Phone:718-830-4359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226061207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY113AV1OtherMEDICARE
NY02370092Medicaid
NY02370092Medicaid