Provider Demographics
NPI:1376523316
Name:SIMON, TIMOTHY M (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:M
Last Name:SIMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 ROBERTS DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-5724
Mailing Address - Country:US
Mailing Address - Phone:870-367-6867
Mailing Address - Fax:870-367-1461
Practice Address - Street 1:906 ROBERTS DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-5724
Practice Address - Country:US
Practice Address - Phone:870-367-6867
Practice Address - Fax:870-367-1461
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2969207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1927600000OtherQUALCHOICE
AR145158001Medicaid
AR145158001Medicaid
ARG98771Medicare UPIN