Provider Demographics
NPI:1760190664
Name:SIMON, TOMAIAH
Entity Type:Individual
Prefix:
First Name:TOMAIAH
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 FARLEY DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-5655
Mailing Address - Country:US
Mailing Address - Phone:510-331-1220
Mailing Address - Fax:
Practice Address - Street 1:7912 WEST LN STE 221
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-3159
Practice Address - Country:US
Practice Address - Phone:209-623-6986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator