Provider Demographics
NPI:1265427447
Name:SIMON, THEODORE (DC)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
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:PO BOX 997
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34220-0997
Mailing Address - Country:US
Mailing Address - Phone:941-776-4000
Mailing Address - Fax:941-845-4963
Practice Address - Street 1:1110 E GIBSON ST
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-5011
Practice Address - Country:US
Practice Address - Phone:863-993-0100
Practice Address - Fax:863-993-2116
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3233111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL380640500Medicaid
FL40213OtherBC/BS OF FLORIDA
FLT55822Medicare UPIN
FL40213OtherBC/BS OF FLORIDA