Provider Demographics
NPI:1740205889
Name:SIMON, ROGER PANCOAST (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:PANCOAST
Last Name:SIMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:720 WESTVIEW DR SW
Mailing Address - Street 2:HARRIS BUILDING STE. 100-A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-1458
Mailing Address - Country:US
Mailing Address - Phone:404-756-1400
Mailing Address - Fax:404-756-1402
Practice Address - Street 1:80 JESSE HILL JR. DR.
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303
Practice Address - Country:US
Practice Address - Phone:404-616-4307
Practice Address - Fax:404-756-1402
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA64970207R00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003100679BMedicaid
OR288365Medicaid
ORA42297Medicare UPIN
OR288365Medicaid