MEDICARE: NETANEL SHIMONOV C. PED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224L00000X	Pedorthist

General Provider Information

NPI Number	:	1699372409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NETANEL SHIMONOV C. PED

Provider Business Mailing Address
First Line	:	1353 45TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-2102
Country	:	US
Telephone Number	:	929-810-4777
Fax Number	:

Provider Business Practice Location Address
First Line	:	1353 45TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-2102
Country	:	US
Telephone Number	:	929-810-4777
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2020
Last Update Date	:	10/05/2020

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