Provider Demographics
NPI:1285653808
Name:SIM, STEPHEN (DPM)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:SIM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2484
Mailing Address - Country:US
Mailing Address - Phone:323-732-7551
Mailing Address - Fax:323-732-7829
Practice Address - Street 1:3130 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2484
Practice Address - Country:US
Practice Address - Phone:323-732-7551
Practice Address - Fax:323-732-7829
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4172213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E41720Medicaid
U72564Medicare UPIN
CA000E41720Medicaid