Provider Demographics
NPI:1245251073
Name:SIMON, ROBERT ALEXANDER (PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ALEXANDER
Last Name:SIMON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 5TH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4230
Mailing Address - Country:US
Mailing Address - Phone:619-220-7680
Mailing Address - Fax:619-220-7682
Practice Address - Street 1:3636 4TH AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4280
Practice Address - Country:US
Practice Address - Phone:619-220-7680
Practice Address - Fax:619-220-7682
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10800103TC0700X, 103TC2200X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY108000Medicaid
CACP10800Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER