Provider Demographics
NPI:1417019837
Name:SIMON, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 WHITE PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-1406
Mailing Address - Country:US
Mailing Address - Phone:718-892-6300
Mailing Address - Fax:718-892-3107
Practice Address - Street 1:2150 WHITE PLAINS RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-1406
Practice Address - Country:US
Practice Address - Phone:718-892-6300
Practice Address - Fax:718-892-3107
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY131708249-001OtherHEALTH FIRST
NY329OtherMONTE
NY01055150Medicaid
NY040401001680OtherCENTER CARE
NY263784OtherHEALTHNET
NY47173000OtherBRONX HEALTH PLAN
NYANC 1649OtherOXFORD
NYG70211OtherEMPIRE BLUE CROSS SHIELD
NY557052OtherAETNA
NYH6549OtherHOMELINK
NYH6549OtherHOMELINK