Provider Demographics
NPI:1063494128
Name:SIMON, LLEWELLYN (MD)
Entity Type:Individual
Prefix:DR
First Name:LLEWELLYN
Middle Name:
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 1:320 N HOOD ST
Mailing Address - Street 2:
Mailing Address - City:LAKE PROVIDENCE
Mailing Address - State:LA
Mailing Address - Zip Code:71254-2140
Mailing Address - Country:US
Mailing Address - Phone:318-559-2404
Mailing Address - Fax:318-559-2430
Practice Address - Street 1:320 N HOOD ST
Practice Address - Street 2:
Practice Address - City:LAKE PROVIDENCE
Practice Address - State:LA
Practice Address - Zip Code:71254-2140
Practice Address - Country:US
Practice Address - Phone:318-559-2404
Practice Address - Fax:318-559-2430
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11828R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA11828ROtherSTATE LICENSE
LA1680893Medicaid
G22424Medicare UPIN
LA1680893Medicaid