Provider Demographics
NPI:1861646093
Name:GRIMBERG, ILONA
Entity Type:Individual
Prefix:MRS
First Name:ILONA
Middle Name:
Last Name:GRIMBERG
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 1:6373 108TH ST
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1607
Mailing Address - Country:US
Mailing Address - Phone:718-896-2020
Mailing Address - Fax:718-459-3490
Practice Address - Street 1:6373 108TH ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1607
Practice Address - Country:US
Practice Address - Phone:718-896-2020
Practice Address - Fax:718-459-3490
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007492-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician