Provider Demographics
NPI:1558583153
Name:NISSIM, JULIE A (DO)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:NISSIM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 FIREMENS MEMORIAL DR
Mailing Address - Street 2:SUITE 115
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-3553
Mailing Address - Country:US
Mailing Address - Phone:800-750-8616
Mailing Address - Fax:
Practice Address - Street 1:25 5TH AVE
Practice Address - Street 2:UNIT #1F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4307
Practice Address - Country:US
Practice Address - Phone:646-681-3308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY242322207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02889063Medicaid
NY50D8606491Medicare PIN
NY02889063Medicaid