Provider Demographics
NPI:1962736611
Name:SIMON, DAVID L (MD, JD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:SIMON
Suffix:
Gender:M
Credentials:MD, JD
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 618
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-0618
Mailing Address - Country:US
Mailing Address - Phone:860-356-2242
Mailing Address - Fax:
Practice Address - Street 1:2 LEDGEBROOK DR FL 2
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1682
Practice Address - Country:US
Practice Address - Phone:860-356-2242
Practice Address - Fax:860-786-1192
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-29
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-050916L207LA0401X
NY60-18004207LA0401X
MA154633207LA0401X
CT013633207LA0401X, 208VP0000X, 208VP0014X, 209800000X
CAG88443207LA0401X
CT13633207LA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No209800000XAllopathic & Osteopathic PhysiciansLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E98093Medicare UPIN