1366772139 NPI number — MARIA VALERIA SIMONE MD

Table of content: MARIA VALERIA SIMONE MD (NPI 1366772139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366772139 NPI number — MARIA VALERIA SIMONE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMONE
Provider First Name:
MARIA
Provider Middle Name:
VALERIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIMONE
Provider Other First Name:
VALERIA
Provider Other Middle Name:
MARIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1366772139
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1545 E SOUTHLAKE BLVD
Provider Second Line Business Mailing Address:
SUITE 140
Provider Business Mailing Address City Name:
SOUTHLAKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76092-6422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-748-0200
Provider Business Mailing Address Fax Number:
817-749-0204

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1545 E SOUTHLAKE BLVD
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
SOUTHLAKE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76092-6422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-748-0200
Provider Business Practice Location Address Fax Number:
817-749-0204
Provider Enumeration Date:
12/30/2009

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: 208600000X , with the licence number:  Q7602 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3203798 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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