Basic Information
| Provider Information | |||||||||
| NPI: | 1376585091 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OVANESSIAN | ||||||||
| FirstName: | SIMON | ||||||||
| MiddleName: | AWADIS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038896147 | ||||||||
| FaxNumber: | 6038831568 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038896147 | ||||||||
| FaxNumber: | 6038831568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 02/16/2018 | ||||||||
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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 | 2084P0800X | 232261 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 042079 | CT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 001420794 | 05 | CT | MEDICAID | P3624013 | 01 | CT | OXFORD | OTHER | 810698118 | 01 | CT | PHCS | OTHER | 343759 | 01 | CO | MANAGED HEALTH NETWORK | OTHER | 537053 | 01 | CT | VALUE OPTIONS | OTHER | 1420794 | 05 | CT | MEDICAID | 15-54607 | 01 | CT | UNITED BEHAVIORAL HEALTH | OTHER |