Provider Demographics
NPI:1467788703
Name:SIMON, ELIZABETH (DO)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6045 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-3246
Mailing Address - Country:US
Mailing Address - Phone:201-861-4443
Mailing Address - Fax:201-861-0941
Practice Address - Street 1:6045 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-3246
Practice Address - Country:US
Practice Address - Phone:201-861-4443
Practice Address - Fax:201-861-0941
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08657400207R00000X
NY255146-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine