Provider Demographics
NPI:1215938139
Name:SHIMONOV, GRIGORIY (OD)
Entity type:Individual
Prefix:DR
First Name:GRIGORIY
Middle Name:
Last Name:SHIMONOV
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15614 CROSSBAY BLVD
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-2745
Mailing Address - Country:US
Mailing Address - Phone:718-738-2020
Mailing Address - Fax:
Practice Address - Street 1:15614 CROSSBAY BLVD
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-2745
Practice Address - Country:US
Practice Address - Phone:718-738-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006831152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06785Medicare PIN
NYV01912Medicare UPIN