Provider Demographics
NPI:1083654081
Name:SIMON, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SIMON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5700 LAKE WORTH RD
Mailing Address - Street 2:#204
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-4727
Mailing Address - Country:US
Mailing Address - Phone:561-968-7968
Mailing Address - Fax:561-964-4603
Practice Address - Street 1:5401 S CONGRESS AVE
Practice Address - Street 2:#102
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-6635
Practice Address - Country:US
Practice Address - Phone:561-967-5033
Practice Address - Fax:561-967-8974
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-10-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME55192207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05047300Medicaid
FL05047300Medicaid
FL09227Medicare PIN