Provider Demographics
NPI:1073502993
Name:SIMON, KENNETH M (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:M
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 1:4255 BOY SCOUT ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168
Mailing Address - Country:US
Mailing Address - Phone:386-478-1977
Mailing Address - Fax:
Practice Address - Street 1:4255 BOY SCOUT CAMP
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-8896
Practice Address - Country:US
Practice Address - Phone:386-478-1977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7658207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254951400Medicaid
FL254951400Medicaid
FLE2574YMedicare PIN