Provider Demographics
NPI:1770589285
Name:PRINCE, SIMON ELLIOT (DO)
Entity type:Individual
Prefix:DR
First Name:SIMON
Middle Name:ELLIOT
Last Name:PRINCE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1129 NORTHERN BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3045
Mailing Address - Country:US
Mailing Address - Phone:516-365-5570
Mailing Address - Fax:516-365-5532
Practice Address - Street 1:1129 NORTHERN BLVD
Practice Address - Street 2:STE 101
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3045
Practice Address - Country:US
Practice Address - Phone:516-365-5570
Practice Address - Fax:516-365-5532
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY223647207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02256797Medicaid
NY02256797Medicaid
NYWEJ531Medicare ID - Type Unspecified