Provider Demographics
NPI:1902849045
Name:SIMONIAN, SIDNEY KAY (DO)
Entity Type:Individual
Prefix:
First Name:SIDNEY
Middle Name:KAY
Last Name:SIMONIAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 E 12 MILE RD BLDG A
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-2653
Mailing Address - Country:US
Mailing Address - Phone:248-547-6656
Mailing Address - Fax:248-547-5407
Practice Address - Street 1:1421 E. 12 MILE
Practice Address - Street 2:BLDG. A
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-2653
Practice Address - Country:US
Practice Address - Phone:248-547-6656
Practice Address - Fax:248-547-5407
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISS0007420207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5630300OtherBLUE CROSS BLUE SHIELD
MI180008618OtherMRRR
MI1856303004OtherBCN
MI382318591OtherCOMMERCIAL
MI8631110001OtherMRPB
MI382318591OtherVISION SERVICE PLAN / VSP
MI139455411Medicaid
MI8631110001OtherMRPB
MI180008618OtherMRRR
MI0441340002Medicare NSC