Provider Demographics
NPI:1174258305
Name:THEBAULT, SIMON DANIEL XAVIER (MD)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:DANIEL XAVIER
Last Name:THEBAULT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:24 CRICKET AVE
Mailing Address - Street 2:APT 408
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003
Mailing Address - Country:US
Mailing Address - Phone:267-588-2244
Mailing Address - Fax:
Practice Address - Street 1:3400 CIVIC CENTER BLVD S
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-316-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4780912084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology