Provider Demographics
NPI:1558339846
Name:SIMON, JONATHAN M (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:SIMON
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 1:601 E ROLLINS ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1248
Mailing Address - Country:US
Mailing Address - Phone:407-303-5600
Mailing Address - Fax:317-705-5047
Practice Address - Street 1:601 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1248
Practice Address - Country:US
Practice Address - Phone:407-200-2355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL675722085R0202X
FLME675722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253640400Medicaid
FL253640400Medicaid
FLE0296WMedicare ID - Type Unspecified