Provider Demographics
NPI:1093115487
Name:SIMON, STEPHEN ADAM
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ADAM
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 1:2042 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401
Mailing Address - Country:US
Mailing Address - Phone:307-851-6368
Mailing Address - Fax:
Practice Address - Street 1:1435 VILLAGE DR DEPT 2801
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84408-2801
Practice Address - Country:US
Practice Address - Phone:801-626-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program