Basic Information
| Provider Information | |||||||||
| NPI: | 1083704811 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAKSHOURI | ||||||||
| FirstName: | SHIMON | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39 TANNERS RD | ||||||||
| Address2: | |||||||||
| City: | LAKE SUCCESS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110201628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9178162722 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10201 66TH RD | ||||||||
| Address2: | FOREST HILLS HOSPITAL, DEPT. OF MEDICINE | ||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113752029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188304359 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 08/09/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 226061 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 113AV1 | 01 | NY | MEDICARE | OTHER | 02370092 | 05 | NY | MEDICAID |