Provider Demographics
NPI:1790755056
Name:SIMONICH, MATTHEW P (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:P
Last Name:SIMONICH
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 1:1919 W US HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1618
Mailing Address - Country:US
Mailing Address - Phone:719-253-7102
Mailing Address - Fax:719-253-7114
Practice Address - Street 1:1919 W US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1618
Practice Address - Country:US
Practice Address - Phone:719-253-7102
Practice Address - Fax:719-253-7114
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO36912207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01369123Medicaid
CO5410910001Medicare NSC
CO01369123Medicaid