Provider Demographics
NPI:1407840952
Name:SIMON, FRED A JR (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:A
Last Name:SIMON
Suffix:JR
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 1:1111 LIGHTHOUSE LANE
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-3824
Mailing Address - Country:US
Mailing Address - Phone:574-533-0348
Mailing Address - Fax:574-533-0277
Practice Address - Street 1:1111 LIGHTHOUSE LANE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-3824
Practice Address - Country:US
Practice Address - Phone:574-533-0348
Practice Address - Fax:574-533-0277
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038692207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E79751Medicare UPIN
223710DMedicare ID - Type Unspecified