1063412609 NPI number — DR. ELIOT HOWARD ZIMBALIST MD

Table of content: ELIZABETH LARSON WEBER LMSW (NPI 1174108203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063412609 NPI number — DR. ELIOT HOWARD ZIMBALIST MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ZIMBALIST
Provider First Name:
ELIOT
Provider Middle Name:
HOWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ZIMBALIST
Provider Other First Name:
ELIOT
Provider Other Middle Name:
HOWARD
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1063412609
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
452 77TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11209-3256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-921-5548
Provider Business Mailing Address Fax Number:
718-921-5781

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
452 77TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11209-3256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-921-5548
Provider Business Practice Location Address Fax Number:
718-921-5781
Provider Enumeration Date:
07/26/2005

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: 207RG0100X , with the licence number:  149213 , 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: 00906441 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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