Provider Demographics
NPI:1134266349
Name:SIMON, JONATHAN DAVID (DC)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DAVID
Last Name:SIMON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 MASSACHUSETTS AVE # 007
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-1430
Mailing Address - Country:US
Mailing Address - Phone:617-497-9474
Mailing Address - Fax:617-868-4357
Practice Address - Street 1:1815 MASSACHUSETTS AVE # 007
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-1430
Practice Address - Country:US
Practice Address - Phone:617-497-9474
Practice Address - Fax:617-868-4357
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MACH 1586111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD814646OtherUSHEALTHCARE ID
MD4400207OtherUNITEDHEALTHCARE ID
MA351074OtherHARVARDPILGRIM ID
MA4615159OtherAETNA ID
MASIY36128OtherBLUECROSSBLUESHIELD ID
MASIY36128OtherBLUECROSSBLUESHIELD ID
MAU66748Medicare UPIN