Provider Demographics
NPI:1821060013
Name:SIMON, MARK A (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:SIMON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 W MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67213-3916
Mailing Address - Country:US
Mailing Address - Phone:316-262-3716
Mailing Address - Fax:316-262-0784
Practice Address - Street 1:1202 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67213-3916
Practice Address - Country:US
Practice Address - Phone:316-262-3716
Practice Address - Fax:316-262-0784
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1386-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS005347OtherBCBS
KS0181170001Medicare NSC
KS005347OtherBCBS
KS017136Medicare ID - Type Unspecified