Basic Information
| Provider Information | |||||||||
| NPI: | 1770589285 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | SIMON | ||||||||
| MiddleName: | ELLIOT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1129 NORTHERN BLVD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | MANHASSET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110303045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163655570 | ||||||||
| FaxNumber: | 5163655532 | ||||||||
| Practice Location | |||||||||
| Address1: | 1129 NORTHERN BLVD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | MANHASSET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110303045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163655570 | ||||||||
| FaxNumber: | 5163655532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 02/12/2013 | ||||||||
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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 | 207RN0300X | 223647 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 02256797 | 05 | NY | MEDICAID |