Basic Information
| Provider Information | |||||||||
| NPI: | 1558583153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NISSIM | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 FIREMENS MEMORIAL DR | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | POMONA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109703553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007508616 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25 5TH AVE | ||||||||
| Address2: | UNIT #1F | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100034307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466813308 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 05/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 242322 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02889063 | 05 | NY | MEDICAID |