Provider Demographics
NPI:1376731588
Name:SIMONSON, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SIMONSON
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 1:1255 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3127
Mailing Address - Country:US
Mailing Address - Phone:504-347-5435
Mailing Address - Fax:504-347-2119
Practice Address - Street 1:1255 AVENUE D
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3127
Practice Address - Country:US
Practice Address - Phone:504-347-5435
Practice Address - Fax:504-347-2119
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD012837207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1146846Medicaid
IAB65149Medicare UPIN
LA1146846Medicaid