Provider Demographics
NPI:1750629416
Name:SIMON, SANFORD (MD)
Entity Type:Individual
Prefix:
First Name:SANFORD
Middle Name:
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 1:6805 HUNTER RUN PLACE
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059
Mailing Address - Country:US
Mailing Address - Phone:502-882-1445
Mailing Address - Fax:
Practice Address - Street 1:6805 HUNTER RUN PLACE
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059
Practice Address - Country:US
Practice Address - Phone:502-882-1445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-30
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO(MO.)-23270207Q00000X
MO23290207Q00000X
KY37131207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine