Provider Demographics
NPI:1851665491
Name:SIMON, JORGE LUIS (MA63525)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:LUIS
Last Name:SIMON
Suffix:
Gender:M
Credentials:MA63525
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13414 SW 22ND TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-1138
Mailing Address - Country:US
Mailing Address - Phone:786-366-6695
Mailing Address - Fax:786-401-7646
Practice Address - Street 1:13414 SW 22ND TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-1138
Practice Address - Country:US
Practice Address - Phone:786-366-6695
Practice Address - Fax:786-401-7646
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA63525225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist