Provider Demographics
NPI:1841237955
Name:SIMON, SCOTT DAVID (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:DAVID
Last Name:SIMON
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:PO BOX 25100
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-5100
Mailing Address - Country:US
Mailing Address - Phone:559-326-1222
Mailing Address - Fax:559-326-1230
Practice Address - Street 1:9834 GENESEE AVE
Practice Address - Street 2:SUITE 416
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1223
Practice Address - Country:US
Practice Address - Phone:858-458-0099
Practice Address - Fax:858-429-7935
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89550208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGI563AOtherMEDICARE GROUP PTAN
CACB228657OtherMEDICARE PTAN
CACB228657OtherMEDICARE PTAN
CAH66804Medicare UPIN