Provider Demographics
NPI:1437655354
Name:SIMON, DOMINIC ANTHONY
Entity Type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:ANTHONY
Last Name:SIMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:981 W ARROW HWY # 370
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2410
Mailing Address - Country:US
Mailing Address - Phone:520-991-3042
Mailing Address - Fax:
Practice Address - Street 1:3532 MONROE ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-6322
Practice Address - Country:US
Practice Address - Phone:951-343-4619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program