Provider Demographics
NPI:1437156494
Name:SIMON, PHYLLIS (MD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 E PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-1915
Mailing Address - Country:US
Mailing Address - Phone:631-425-2121
Mailing Address - Fax:631-425-2193
Practice Address - Street 1:180 E PULASKI RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-1915
Practice Address - Country:US
Practice Address - Phone:631-425-2121
Practice Address - Fax:631-425-2193
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144918-1207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00718396Medicaid
NY70A851Medicare ID - Type Unspecified
NY00718396Medicaid