Healthcare Provider Details

I. General information

NPI: 1235338138
Provider Name (Legal Business Name): SIMON LIPETZ MD. P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104-60 QUEENS BLVD SUITE CH
FOREST HILLS NY
11375
US

IV. Provider business mailing address

104-60 QUEENS BLVD. SUITE CH
FOREST HILLS NY
11375
US

V. Phone/Fax

Practice location:
  • Phone: 718-275-4849
  • Fax: 718-275-6381
Mailing address:
  • Phone: 718-275-4849
  • Fax: 718-275-6381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number458751
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number107463
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number186190
License Number StateNY

VIII. Authorized Official

Name: SIMON LIPETZ
Title or Position: OWNER
Credential:
Phone: 718-275-4849