Provider Demographics
NPI:1922014596
Name:SIMON, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
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 1:534 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-1642
Mailing Address - Country:US
Mailing Address - Phone:718-448-6293
Mailing Address - Fax:
Practice Address - Street 1:2601 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7745
Practice Address - Country:US
Practice Address - Phone:718-616-4408
Practice Address - Fax:718-616-4105
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002065-2207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02518981Medicaid
NYI02465Medicare UPIN
NY3X4421Medicare ID - Type Unspecified