Provider Demographics
NPI:1053307694
Name:SIMON, MARK TERRANCE
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:TERRANCE
Last Name:SIMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 WALES AVE NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-2323
Mailing Address - Country:US
Mailing Address - Phone:330-832-3188
Mailing Address - Fax:330-832-9936
Practice Address - Street 1:2300 WALES AVE NW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-2323
Practice Address - Country:US
Practice Address - Phone:330-832-3188
Practice Address - Fax:330-832-9936
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-002783-S207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0395255Medicaid
OHC01638Medicare UPIN
OHSI0462471Medicare ID - Type Unspecified