Healthcare Provider Details

I. General information

NPI: 1215384912
Provider Name (Legal Business Name): MEDICAL OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 GRAND ST
BROOKLYN NY
11211-5797
US

IV. Provider business mailing address

765 GRAND ST
BROOKLYN NY
11211-5797
US

V. Phone/Fax

Practice location:
  • Phone: 718-388-7283
  • Fax: 718-963-3410
Mailing address:
  • Phone: 718-388-7283
  • Fax: 718-963-3410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number162398
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number162398
License Number StateNY

VIII. Authorized Official

Name: DR. JOSE RODRIGUEZ SIMPAO JR.
Title or Position: PHYSICIAN
Credential: MD
Phone: 718-388-7283