Provider Demographics
NPI:1962465054
Name:SIMO, SALVADOR MIGUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SALVADOR
Middle Name:MIGUEL
Last Name:SIMO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MIGUEL
Other - Middle Name:
Other - Last Name:SIMO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:12008 SOUTHSHORE BLVD.
Mailing Address - Street 2:STE. 101
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-8502
Mailing Address - Country:US
Mailing Address - Phone:561-429-3812
Mailing Address - Fax:561-429-3891
Practice Address - Street 1:1497 FOREST HILL BLVD STE E
Practice Address - Street 2:
Practice Address - City:LAKE CLARKE SHORES
Practice Address - State:FL
Practice Address - Zip Code:33406-6052
Practice Address - Country:US
Practice Address - Phone:561-433-5687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0044968207QA0401X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL043524400Medicaid
FL043524400Medicaid