Healthcare Provider Details

I. General information

NPI: 1487749685
Provider Name (Legal Business Name): AISHA KIMBERLY PRIM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2780 RESERVOIR AVE
BRONX NY
10468-2702
US

IV. Provider business mailing address

352 HUSSEY RD
MOUNT VERNON NY
10552-2338
US

V. Phone/Fax

Practice location:
  • Phone: 718-329-8589
  • Fax: 718-527-5624
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number216856
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: