1831218031 NPI number — DR. NAOMI SOROOSH SIMON MD

Table of content: DR. NAOMI SOROOSH SIMON MD (NPI 1831218031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831218031 NPI number — DR. NAOMI SOROOSH SIMON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMON
Provider First Name:
NAOMI
Provider Middle Name:
SOROOSH
Provider Name Prefix Text:
DR.
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:
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:
1831218031
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1845
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STATESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28687-1845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-235-1827
Provider Business Mailing Address Fax Number:
704-235-1823

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128 MEDICAL PARK RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
MOORESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28117-8578
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-235-1827
Provider Business Practice Location Address Fax Number:
704-235-1823
Provider Enumeration Date:
03/28/2007

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: 207N00000X , with the licence number:  2008-00134 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5914416 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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