Provider Demographics
NPI:1629075767
Name:HAIMOVIC, ITZHAK C (MD)
Entity Type:Individual
Prefix:
First Name:ITZHAK
Middle Name:C
Last Name:HAIMOVIC
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 1:170 GREAT NECK ROAD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021
Mailing Address - Country:US
Mailing Address - Phone:516-487-4464
Mailing Address - Fax:516-487-4950
Practice Address - Street 1:170 GREAT NECK ROAD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021
Practice Address - Country:US
Practice Address - Phone:516-487-4464
Practice Address - Fax:516-487-4950
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1296502084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01008626Medicaid
B14910Medicare UPIN
NY01008626Medicaid