Provider Demographics
NPI:1619013778
Name:SIMON, MARC LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:LEE
Last Name:SIMON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16 POCONO RD STE 310
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2908
Mailing Address - Country:US
Mailing Address - Phone:973-627-4227
Mailing Address - Fax:973-627-2066
Practice Address - Street 1:16 POCONO RD STE 310
Practice Address - Street 2:
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2908
Practice Address - Country:US
Practice Address - Phone:973-627-4227
Practice Address - Fax:973-664-7572
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB03674200208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1607901Medicaid
NJ453135Medicare PIN