Provider Demographics
NPI:1316000417
Name:SIMONI, SUZANNE ELIZABETH
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:ELIZABETH
Last Name:SIMONI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 PACIFIC AVENUE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204
Mailing Address - Country:US
Mailing Address - Phone:209-943-0502
Mailing Address - Fax:209-943-0243
Practice Address - Street 1:2904 PACIFIC AVENUE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204
Practice Address - Country:US
Practice Address - Phone:209-943-0502
Practice Address - Fax:209-943-0243
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0207940111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
44518Medicare ID - Type Unspecified
DC020794Medicare UPIN