Provider Demographics
NPI:1922082957
Name:SIMON, SHELDON (DPM)
Entity Type:Individual
Prefix:
First Name:SHELDON
Middle Name:
Last Name:SIMON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 W PARRISH AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-3519
Mailing Address - Country:US
Mailing Address - Phone:270-683-4844
Mailing Address - Fax:270-926-8366
Practice Address - Street 1:1915 W PARRISH AVE
Practice Address - Street 2:STE 300
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-3519
Practice Address - Country:US
Practice Address - Phone:270-683-4844
Practice Address - Fax:270-926-8366
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY119213E00000X
IN07000335A213E00000X
KY00119213ES0000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY80001191Medicaid
IN100027980AMedicaid
KY000000045182OtherANTHEM
KY45803004Medicaid
KY90270307Medicaid
IN100027980AMedicaid
KY000000045182OtherANTHEM
KY45803004Medicaid
KY0248600001Medicare NSC
KY1678801Medicare PIN