Provider Demographics
NPI:1073565511
Name:SIMON, JONATHAN T (MD)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:T
Last Name:SIMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:67 MAPLE AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1328
Mailing Address - Country:US
Mailing Address - Phone:203-732-1330
Mailing Address - Fax:203-732-1332
Practice Address - Street 1:22 WESTFIELD AVE
Practice Address - Street 2:
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401
Practice Address - Country:US
Practice Address - Phone:203-736-9919
Practice Address - Fax:203-735-2055
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234884207R00000X, 207RG0100X
CT46849207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008002867Medicaid
A33124Medicare UPIN
NY02661067Medicaid