Provider Demographics
NPI:1598381667
Name:SIMON, PETER (CST)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:SIMON
Suffix:
Gender:M
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 SW SOUNDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34431-3172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3505 SW SOUNDVIEW DR
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34431-3172
Practice Address - Country:US
Practice Address - Phone:561-797-7169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS550-660-69-422-0OtherDRIVER LICENSE