Provider Demographics
NPI:1811176837
Name:FRED J SIMON, JR., M.D.
Entity type:Organization
Organization Name:FRED J SIMON, JR., M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:858-626-6362
Mailing Address - Street 1:PO BOX 85466
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92186-5466
Mailing Address - Country:US
Mailing Address - Phone:858-626-6362
Mailing Address - Fax:858-626-6354
Practice Address - Street 1:9888 GENESEE AVE
Practice Address - Street 2:LJ-601
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1205
Practice Address - Country:US
Practice Address - Phone:858-626-6362
Practice Address - Fax:858-626-6354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-26
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42394208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C423940Medicaid
CAW18930Medicare PIN