Healthcare Provider Details

I. General information

NPI: 1912072091
Provider Name (Legal Business Name): MIHAI TIBERIU SIMIONESCU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 ERIE BLVD E SUITE 214
SYRACUSE NY
13210-1148
US

IV. Provider business mailing address

4723 ANGLIA ST
MANLIUS NY
13104-9798
US

V. Phone/Fax

Practice location:
  • Phone: 315-401-7436
  • Fax: 315-401-7436
Mailing address:
  • Phone: 315-637-8987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number259598
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number259598
License Number StateNY

VII. Legacy identifiers

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

# 1
Identifier00354485
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: