Provider Demographics
NPI:1235245036
Name:SIMON, COLETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:COLETTE
Middle Name:
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 1:2603 KEISER BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-3356
Mailing Address - Country:US
Mailing Address - Phone:484-628-3939
Mailing Address - Fax:
Practice Address - Street 1:2603 KEISER BLVD STE 204
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-3356
Practice Address - Country:US
Practice Address - Phone:484-628-3939
Practice Address - Fax:484-628-3940
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4527662083P0011X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA072790OtherMEDICARE PTAN
F55058Medicare UPIN