Provider Demographics
NPI:1326617036
Name:SIMON, VLADEMIR CARMEL
Entity Type:Individual
Prefix:
First Name:VLADEMIR
Middle Name:CARMEL
Last Name:SIMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 LOCUST AVE N
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1604
Mailing Address - Country:US
Mailing Address - Phone:215-303-6284
Mailing Address - Fax:
Practice Address - Street 1:6 LOCUST AVE N
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-1604
Practice Address - Country:US
Practice Address - Phone:215-303-6284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY655816163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse