Provider Demographics
NPI:1013990266
Name:SIMON, MATTHEW D (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:D
Last Name:SIMON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7469 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2216
Mailing Address - Country:US
Mailing Address - Phone:954-792-0772
Mailing Address - Fax:954-792-1221
Practice Address - Street 1:7469 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2216
Practice Address - Country:US
Practice Address - Phone:954-792-0772
Practice Address - Fax:954-792-1221
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6724103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ26152Medicare UPIN
FL74290AMedicare ID - Type Unspecified