Provider Demographics
NPI:1326166125
Name:SIMON, MARY A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:A
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 1:7 MELROSE DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-0893
Mailing Address - Country:US
Mailing Address - Phone:860-677-1778
Mailing Address - Fax:860-677-1730
Practice Address - Street 1:7 MELROSE DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-0893
Practice Address - Country:US
Practice Address - Phone:860-677-1778
Practice Address - Fax:860-677-1730
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0360492080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001 360 495Medicaid
CT001 360 495Medicaid