Provider Demographics
NPI:1194827998
Name:SIMONSON, MARK JOHN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:SIMONSON
Suffix:
Gender:M
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:PO BOX 2509
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-2509
Mailing Address - Country:US
Mailing Address - Phone:907-260-5455
Mailing Address - Fax:907-714-3111
Practice Address - Street 1:240 HOSPITAL PL STE 204B
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7559
Practice Address - Country:US
Practice Address - Phone:907-714-4120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD44242081P2900X, 208VP0014X
WY6326A2081P2900X, 208VP0014X
CAC516042081P2900X, 208VP0014X
AKMEDS8005208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6334Medicare ID - Type Unspecified
CAW20279Medicare PIN
G21682Medicare UPIN