Provider Demographics
NPI:1083786024
Name:SIMON, JACK HOWARD (MD,PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:HOWARD
Last Name:SIMON
Suffix:
Gender:M
Credentials:MD,PHD
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:HOWARD
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD,PHD
Mailing Address - Street 1:PO BOX 3980
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-1540
Mailing Address - Country:US
Mailing Address - Phone:303-819-2848
Mailing Address - Fax:
Practice Address - Street 1:3710 SW VETERANS HOSPITAL RD
Practice Address - Street 2:PORTLAND VA MEDICAL CENTER
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97207
Practice Address - Country:US
Practice Address - Phone:303-819-2848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO235222085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology