Provider Demographics
NPI:1518566793
Name:SIMON, MIKAELA ROSA (OD)
Entity Type:Individual
Prefix:DR
First Name:MIKAELA
Middle Name:ROSA
Last Name:SIMON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 MECHANIC ST
Mailing Address - Street 2:
Mailing Address - City:FOXBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02035-2011
Mailing Address - Country:US
Mailing Address - Phone:508-543-4840
Mailing Address - Fax:508-698-1013
Practice Address - Street 1:316 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:MA
Practice Address - Zip Code:02766-2100
Practice Address - Country:US
Practice Address - Phone:508-223-5552
Practice Address - Fax:508-698-1013
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5430152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist