Provider Demographics
NPI:1427164599
Name:SIMON, JERALD IRA (MD)
Entity type:Individual
Prefix:DR
First Name:JERALD
Middle Name:IRA
Last Name:SIMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4272 STALWART DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275
Mailing Address - Country:US
Mailing Address - Phone:310-541-3164
Mailing Address - Fax:
Practice Address - Street 1:24050 MADISON ST
Practice Address - Street 2:SUITE 217
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505
Practice Address - Country:US
Practice Address - Phone:310-375-8501
Practice Address - Fax:310-375-7952
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC253582084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
A32854Medicare UPIN
CAC25358Medicare ID - Type Unspecified