Provider Demographics
NPI:1639368541
Name:ROBERT E SIMON MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ROBERT E SIMON MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:E
Authorized Official - Last Name:EASTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-364-9054
Mailing Address - Street 1:26691 PLAZA
Mailing Address - Street 2:SUITE 235
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6329
Mailing Address - Country:US
Mailing Address - Phone:949-364-9054
Mailing Address - Fax:949-364-6171
Practice Address - Street 1:26691 PLAZA
Practice Address - Street 2:SUITE 235
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6329
Practice Address - Country:US
Practice Address - Phone:949-364-9054
Practice Address - Fax:949-364-6171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13948Medicare PIN