Provider Demographics
NPI:1790883452
Name:GLASS, SIMON DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:DAVID
Last Name:GLASS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:S
Other - Middle Name:DAVID
Other - Last Name:GLASS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4500 KRUSE WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035
Mailing Address - Country:US
Mailing Address - Phone:503-475-5750
Mailing Address - Fax:503-636-0722
Practice Address - Street 1:4500 KRUSE WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035
Practice Address - Country:US
Practice Address - Phone:503-475-5750
Practice Address - Fax:503-636-0722
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR134162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry