Provider Demographics
NPI:1790785285
Name:SIMON, JESSICA A (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:A
Last Name:SIMON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-2117
Mailing Address - Country:US
Mailing Address - Phone:330-630-9699
Mailing Address - Fax:
Practice Address - Street 1:3330 KENT RD
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-4537
Practice Address - Country:US
Practice Address - Phone:330-688-8811
Practice Address - Fax:330-296-3231
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2019-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5416152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHV00713Medicare UPIN
OHSI4139181Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE
OHSI4139181Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE