Provider Demographics
NPI:1457329492
Name:SIMON, ROBERT JEFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JEFFREY
Last Name:SIMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2944 MANNING AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064
Mailing Address - Country:US
Mailing Address - Phone:310-842-7575
Mailing Address - Fax:310-842-7878
Practice Address - Street 1:13320 RIVERSIDE DRIVE
Practice Address - Street 2:#214
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423
Practice Address - Country:US
Practice Address - Phone:818-789-0451
Practice Address - Fax:818-789-9599
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46574207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A46574OMedicaid
BS2111564OtherDEA
CA00A46574OMedicaid
CAA46574Medicare ID - Type Unspecified