Provider Demographics
NPI: | 1932295029 |
---|---|
Name: | SIMONS, MICHAEL HOWARD (DPM) |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHAEL |
Middle Name: | HOWARD |
Last Name: | SIMONS |
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: | 18111 BROOKHURST ST |
Mailing Address - Street 2: | SUITE 3400 |
Mailing Address - City: | FOUNTAIN VALLEY |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92708-6728 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 714-847-1150 |
Mailing Address - Fax: | 714-848-6976 |
Practice Address - Street 1: | 18111 BROOKHURST ST |
Practice Address - Street 2: | SUITE 3400 |
Practice Address - City: | FOUNTAIN VALLEY |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92708-6728 |
Practice Address - Country: | US |
Practice Address - Phone: | 714-847-1150 |
Practice Address - Fax: | 714-848-6976 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-10-05 |
Last Update Date: | 2009-10-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | E1388 | 213ES0103X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 213ES0103X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 000E13880 | Medicaid | |
P00110039 | Other | RAILROAD MEDICARE | |
CA | 0374540001 | Medicare NSC | |
P00110039 | Other | RAILROAD MEDICARE |