Provider Demographics
NPI:1194956490
Name:SIMON, SEGUN V (MD)
Entity type:Individual
Prefix:DR
First Name:SEGUN
Middle Name:V
Last Name:SIMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:PO BOX 373
Mailing Address - Street 2:
Mailing Address - City:SHORT HILLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07078-0373
Mailing Address - Country:US
Mailing Address - Phone:973-996-2727
Mailing Address - Fax:973-763-2558
Practice Address - Street 1:2130 MILLBURN AVE
Practice Address - Street 2:SUITE C-3
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3725
Practice Address - Country:US
Practice Address - Phone:973-996-2727
Practice Address - Fax:973-763-2558
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2014-11-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA08683000207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0371254Medicaid
NJ2074021Medicare PIN