Provider Demographics
NPI:1962412478
Name:SIMON, TODD L
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:L
Last Name:SIMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7490
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:07702
Mailing Address - Country:US
Mailing Address - Phone:718-780-5131
Mailing Address - Fax:718-780-3389
Practice Address - Street 1:506 6TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215
Practice Address - Country:US
Practice Address - Phone:718-780-5131
Practice Address - Fax:718-780-3389
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07648700207R00000X
NY191458207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01506321Medicaid
NY01506321Medicaid
NY11J981Medicare PIN