Provider Demographics
NPI:1275618217
Name:SIMON, PAUL B (DO, MSSA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:B
Last Name:SIMON
Suffix:
Gender:M
Credentials:DO, MSSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:255 SPENCER RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-2494
Mailing Address - Country:US
Mailing Address - Phone:636-939-2550
Mailing Address - Fax:636-939-2551
Practice Address - Street 1:255 SPENCER RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-2494
Practice Address - Country:US
Practice Address - Phone:636-939-2550
Practice Address - Fax:636-939-2551
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050191152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1275618217Medicaid
MO1275618217Medicare PIN