Provider Demographics
NPI:1356832398
Name:SIMON, THOMAS BULLOCK (DPM)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:BULLOCK
Last Name:SIMON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6405 S 3000 E STE 300
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6977
Mailing Address - Country:US
Mailing Address - Phone:801-266-3113
Mailing Address - Fax:801-931-2166
Practice Address - Street 1:6405 S 3000 E STE 300
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84121-6977
Practice Address - Country:US
Practice Address - Phone:801-266-3113
Practice Address - Fax:801-931-2166
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT17-2018213E00000X
UT12286299-0501213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4071953Medicaid