Provider Demographics
NPI:1821069311
Name:SIMON, KEITH A (OD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
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:PO BOX 57624
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91413-2624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:604 ROSE AVE
Practice Address - Street 2:VENICE FAMILY CLINIC/OPTOMETRY DEPT.
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2767
Practice Address - Country:US
Practice Address - Phone:310-392-8636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10592 TPG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU91570Medicare UPIN