Basic Information
| Provider Information | |||||||||
| NPI: | 1962465054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMO | ||||||||
| FirstName: | SALVADOR | ||||||||
| MiddleName: | MIGUEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIMO | ||||||||
| OtherFirstName: | MIGUEL | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12008 SOUTHSHORE BLVD. | ||||||||
| Address2: | STE. 101 | ||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334148502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614293812 | ||||||||
| FaxNumber: | 5614293891 | ||||||||
| Practice Location | |||||||||
| Address1: | 1497 FOREST HILL BLVD STE E | ||||||||
| Address2: | |||||||||
| City: | LAKE CLARKE SHORES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334066052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614335687 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | 0044968 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 208000000X | 0044968 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 043524400 | 05 | FL | MEDICAID |