Provider Demographics
NPI:1336189810
Name:SIMONIAN, SIMON JOHN (MD)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:JOHN
Last Name:SIMONIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7616 LAUREL LEAF DR
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-1763
Mailing Address - Country:US
Mailing Address - Phone:301-983-8856
Mailing Address - Fax:
Practice Address - Street 1:3301 WOODBURN RD
Practice Address - Street 2:SUITE 202
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-1229
Practice Address - Country:US
Practice Address - Phone:703-573-5500
Practice Address - Fax:703-573-3620
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01011045316174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB73475Medicare UPIN