Provider Demographics
NPI:1962776724
Name:SIMONIAN, VIC SAM (MD)
Entity type:Individual
Prefix:DR
First Name:VIC
Middle Name:SAM
Last Name:SIMONIAN
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 1:6 BURNING TREE
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-5305
Mailing Address - Country:US
Mailing Address - Phone:949-496-2482
Mailing Address - Fax:
Practice Address - Street 1:6 BURNING TREE
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-5305
Practice Address - Country:US
Practice Address - Phone:949-496-2482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-25
Last Update Date:2012-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34745207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine