Provider Demographics
NPI:1407828684
Name:WARREN, SIMON JOHN (MD)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:JOHN
Last Name:WARREN
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 1:635 BARNHILL DR # A128
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5126
Mailing Address - Country:US
Mailing Address - Phone:317-274-4806
Mailing Address - Fax:
Practice Address - Street 1:635 BARNHILL DR # A128
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5126
Practice Address - Country:US
Practice Address - Phone:317-274-4806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93737174400000X
IN01065084A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL030682700Medicaid
IN200894770Medicaid
IN824330VVVVMedicare PIN
FLH39396Medicare UPIN
FL030682700Medicaid