Basic Information
| Provider Information | |||||||||
| NPI: | 1205891512 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIMON | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4102 N ROXBORO ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195952000 | ||||||||
| FaxNumber: | 9195952190 | ||||||||
| Practice Location | |||||||||
| Address1: | 4102 N ROXBORO ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195952000 | ||||||||
| FaxNumber: | 9195952190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 09/22/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | TL28671 | SC | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 2006-00474 | NC | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 2006-00474 | 01 | NC | NC MEDICAL LICENSE | OTHER | TL28671 | 01 | SC | SC MEDICAL LICENSE | OTHER |