Healthcare Provider Details

I. General information

NPI: 1407896251
Provider Name (Legal Business Name): SIMKI SHAH OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 01/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 S MAPLE AVE
GLEN ROCK NJ
07452-2820
US

IV. Provider business mailing address

1005 S MAPLE AVE
GLEN ROCK NJ
07452-2820
US

V. Phone/Fax

Practice location:
  • Phone: 201-444-8277
  • Fax:
Mailing address:
  • Phone: 201-444-8277
  • Fax: 201-444-8849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00592000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: