Provider Demographics
NPI:1992862205
Name:SIMON, MICHAEL WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:SIMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:610 E BRANNON RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-6066
Mailing Address - Country:US
Mailing Address - Phone:859-277-6516
Mailing Address - Fax:859-277-1521
Practice Address - Street 1:610 E BRANNON RD
Practice Address - Street 2:SUITE 201
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-6066
Practice Address - Country:US
Practice Address - Phone:859-277-6516
Practice Address - Fax:859-277-1521
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY22740208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64227408Medicaid