Provider Demographics
NPI:1043207533
Name:SIMON, MARK O (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:O
Last Name:SIMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70087
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-0087
Mailing Address - Country:US
Mailing Address - Phone:907-460-6667
Mailing Address - Fax:
Practice Address - Street 1:1650 COWLES ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5925
Practice Address - Country:US
Practice Address - Phone:907-458-5556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4813207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD2451Medicaid
AKMD2451Medicaid
H13781Medicare UPIN