Healthcare Provider Details

I. General information

NPI: 1124063219
Provider Name (Legal Business Name): MERI NISIMOVA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8900 VAN WYCK EXPY DEPT. OF PSYCHIATRY
RICHMOND HILL NY
11418-2832
US

IV. Provider business mailing address

8900 VAN WYCK EXPY
JAMAICA NY
11418-2832
US

V. Phone/Fax

Practice location:
  • Phone: 718-206-7160
  • Fax: 718-206-7169
Mailing address:
  • Phone: 718-206-7160
  • Fax: 718-206-7169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number235257
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: