1023050929 NPI number — CYRIL M SIMON D.O.

Table of content: CYRIL M SIMON D.O. (NPI 1023050929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023050929 NPI number — CYRIL M SIMON D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMON
Provider First Name:
CYRIL
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023050929
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 N MAIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOVINGTON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88260-2830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-396-6611
Provider Business Mailing Address Fax Number:
575-396-1454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 N MAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOVINGTON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88260-2830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-396-6611
Provider Business Practice Location Address Fax Number:
575-396-1454
Provider Enumeration Date:
06/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  25MB08021000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD2015-0518 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 41423836 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2970309 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".