Provider Demographics
NPI:1073399671
Name:SIMON, SAMUEL MYRON
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:MYRON
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 1:10671 N KENDALL DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-1510
Mailing Address - Country:US
Mailing Address - Phone:786-416-0811
Mailing Address - Fax:786-558-5483
Practice Address - Street 1:10671 N KENDALL DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-1510
Practice Address - Country:US
Practice Address - Phone:786-416-0811
Practice Address - Fax:786-558-5483
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty