Provider Demographics
NPI:1558314732
Name:WALDFOGEL, SHIMON (MD)
Entity type:Individual
Prefix:
First Name:SHIMON
Middle Name:
Last Name:WALDFOGEL
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 1:8244 NEW SECOND ST
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-1723
Mailing Address - Country:US
Mailing Address - Phone:215-481-2589
Mailing Address - Fax:215-481-7570
Practice Address - Street 1:1245 HIGHLAND AVE
Practice Address - Street 2:308
Practice Address - City:ABINGTON
Practice Address - State:PA
Practice Address - Zip Code:19001-3714
Practice Address - Country:US
Practice Address - Phone:215-481-2589
Practice Address - Fax:215-481-7570
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040230L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA557654Medicare ID - Type Unspecified