Provider Demographics
NPI:1790728103
Name:SIMON, JEFFREY LAWRENCE (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LAWRENCE
Last Name:SIMON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28-02 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3913
Mailing Address - Country:US
Mailing Address - Phone:201-791-6267
Mailing Address - Fax:201-791-6667
Practice Address - Street 1:28-02 BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3913
Practice Address - Country:US
Practice Address - Phone:201-791-6267
Practice Address - Fax:201-791-6667
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD0001075213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
160555Medicare ID - Type Unspecified
0569380001Medicare NSC