Basic Information
| Provider Information | |||||||||
| NPI: | 1245324300 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIMON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 147026 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326147026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523319729 | ||||||||
| FaxNumber: | 3523310136 | ||||||||
| Practice Location | |||||||||
| Address1: | 6716 NW 11 PLACE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523319729 | ||||||||
| FaxNumber: | 3523310136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 08/20/2012 | ||||||||
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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 | 2085N0700X | ME41611 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | ME41611 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 94360 | 01 | FL | BC | OTHER |