Provider Demographics
NPI:1215662846
Name:NISIMOVA, SERAFIMA (OD)
Entity type:Individual
Prefix:
First Name:SERAFIMA
Middle Name:
Last Name:NISIMOVA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8207 TRYON PL
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1440
Mailing Address - Country:US
Mailing Address - Phone:718-844-4731
Mailing Address - Fax:
Practice Address - Street 1:9519 63RD DR
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2024
Practice Address - Country:US
Practice Address - Phone:718-459-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV009572152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist