Provider Demographics
NPI:1568923936
Name:SIMONSEN, MAX WIKNE (MD)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:WIKNE
Last Name:SIMONSEN
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 1:5999 BURKE COMMONS RD
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-2880
Mailing Address - Country:US
Mailing Address - Phone:202-845-5327
Mailing Address - Fax:
Practice Address - Street 1:825 FAIRFAX AVE STE 710
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1912
Practice Address - Country:US
Practice Address - Phone:757-446-5884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101278229390200000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program