Provider Demographics
NPI:1245315142
Name:SIMON, JONATHAN M
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:SIMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 PINEHURST AVE
Mailing Address - Street 2:B 33
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-1755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 E 55TH ST
Practice Address - Street 2:STE 106
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-4148
Practice Address - Country:US
Practice Address - Phone:212-224-0087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001754171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist