Provider Demographics
NPI:1851402002
Name:OUTHWAITE, SIMON G (MD)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:G
Last Name:OUTHWAITE
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 1:647 CAMINO DE LOS MARES #108-167
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2841
Mailing Address - Country:US
Mailing Address - Phone:949-493-6958
Mailing Address - Fax:949-388-6969
Practice Address - Street 1:647 CAMINO DE LOS MARES #108-167
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2841
Practice Address - Country:US
Practice Address - Phone:949-493-6958
Practice Address - Fax:949-388-6969
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG80528207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG37064Medicare UPIN