Provider Demographics
NPI:1609802628
Name:SIMON, MICHAEL JOHNSON (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHNSON
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 1:567 AVENUE K SE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4215
Mailing Address - Country:US
Mailing Address - Phone:863-299-1231
Mailing Address - Fax:863-299-1233
Practice Address - Street 1:200 AVENUE F NE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4131
Practice Address - Country:US
Practice Address - Phone:863-293-1121
Practice Address - Fax:844-876-0873
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36347207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061591900Medicaid
FL68236Medicare ID - Type Unspecified