Provider Demographics
NPI:1245324300
Name:SIMON, MARK J (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:SIMON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 147026
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32614-7026
Mailing Address - Country:US
Mailing Address - Phone:352-331-9729
Mailing Address - Fax:352-331-0136
Practice Address - Street 1:6716 NW 11 PLACE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605
Practice Address - Country:US
Practice Address - Phone:352-331-9729
Practice Address - Fax:352-331-0136
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME416112085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL94360OtherBC
FLD64692Medicare UPIN