Healthcare Provider Details

I. General information

NPI: 1770589285
Provider Name (Legal Business Name): SIMON ELLIOT PRINCE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 NORTHERN BLVD STE 101
MANHASSET NY
11030-3045
US

IV. Provider business mailing address

1129 NORTHERN BLVD STE 101
MANHASSET NY
11030-3045
US

V. Phone/Fax

Practice location:
  • Phone: 516-365-5570
  • Fax: 516-365-5532
Mailing address:
  • Phone: 516-365-5570
  • Fax: 516-365-5532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number223647
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02256797
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: