Provider Demographics
NPI:1851365449
Name:SIMON, ROBERT M (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
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 1:6 HIGHRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-1409
Mailing Address - Country:US
Mailing Address - Phone:917-853-2232
Mailing Address - Fax:
Practice Address - Street 1:6 HIGHRIDGE RD
Practice Address - Street 2:
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538-1409
Practice Address - Country:US
Practice Address - Phone:917-853-2232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163710204C00000X, 208100000X
CT035038208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY133884168Other1199
NY01644751/02338970Medicaid
NY133884168Other1199
NY75F511/W2L683Medicare ID - Type Unspecified
NYWYQYY1Medicare PIN
NYWYQYZ1Medicare PIN
NY01644751/02338970Medicaid