Provider Demographics
NPI:1124197157
Name:CARVAJAL, SIMEON (MD)
Entity Type:Individual
Prefix:DR
First Name:SIMEON
Middle Name:
Last Name:CARVAJAL
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 1:613 KINDERKAMACK RD
Mailing Address - Street 2:
Mailing Address - City:ORADELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07649-1503
Mailing Address - Country:US
Mailing Address - Phone:718-518-5550
Mailing Address - Fax:718-838-1010
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7606
Practice Address - Country:US
Practice Address - Phone:718-518-5550
Practice Address - Fax:718-838-1010
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115792174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00214186Medicaid
NY565361Medicare ID - Type Unspecified
NY00214186Medicaid