Provider Demographics
NPI:1154486249
Name:SIMON, LAURA J (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:J
Last Name:SIMON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3524 E MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-1626
Mailing Address - Country:US
Mailing Address - Phone:608-756-7100
Mailing Address - Fax:
Practice Address - Street 1:3524 E MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-1626
Practice Address - Country:US
Practice Address - Phone:608-756-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33569207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036045907 2Medicaid
WI31883100Medicaid
IL036045907 2Medicaid
D13917Medicare UPIN
WI110083931 CD3624Medicare PIN