1558583153 NPI number — JULIE A NISSIM D.O

Table of content: JULIE A NISSIM D.O (NPI 1558583153)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558583153 NPI number — JULIE A NISSIM D.O

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NISSIM
Provider First Name:
JULIE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558583153
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26 FIREMENS MEMORIAL DR
Provider Second Line Business Mailing Address:
SUITE 115
Provider Business Mailing Address City Name:
POMONA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10970-3553
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-750-8616
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 5TH AVE
Provider Second Line Business Practice Location Address:
UNIT #1F
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10003-4307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-681-3308
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  242322 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02889063 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com