Provider Demographics
NPI:1023216694
Name:SIMON, FRED (DO)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:
Last Name:SIMON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62917 PEACH RD
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-9124
Mailing Address - Country:US
Mailing Address - Phone:970-249-8571
Mailing Address - Fax:
Practice Address - Street 1:62917 PEACH RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-9124
Practice Address - Country:US
Practice Address - Phone:970-249-8571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR-18928207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COE40409Medicare UPIN