Provider Demographics
NPI:1376806554
Name:SIMON MD PA
Entity Type:Organization
Organization Name:SIMON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:MIGUEL
Authorized Official - Last Name:SIMON CANELLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-608-0656
Mailing Address - Street 1:PO BOX 831975
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33283-1975
Mailing Address - Country:US
Mailing Address - Phone:305-608-0656
Mailing Address - Fax:786-254-7084
Practice Address - Street 1:3850 SW 87TH AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-5474
Practice Address - Country:US
Practice Address - Phone:305-608-0656
Practice Address - Fax:786-254-7084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1121492084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006437100Medicaid