Provider Demographics
NPI:1093825556
Name:SIMON, ROBERT S (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:SIMON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 E DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-6350
Mailing Address - Country:US
Mailing Address - Phone:352-787-1956
Mailing Address - Fax:352-365-6690
Practice Address - Street 1:112 E DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6350
Practice Address - Country:US
Practice Address - Phone:352-787-1956
Practice Address - Fax:352-365-6690
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4385152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009661800Medicaid
FLGZ407ZMedicare Oscar/Certification
FL009661800Medicaid
TN3597147Medicare ID - Type Unspecified