Healthcare Provider Details

I. General information

NPI: 1811176837
Provider Name (Legal Business Name): FRED J SIMON, JR., M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2007
Last Update Date: 11/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9888 GENESEE AVE LJ-601
LA JOLLA CA
92037-1205
US

IV. Provider business mailing address

PO BOX 85466
SAN DIEGO CA
92186-5466
US

V. Phone/Fax

Practice location:
  • Phone: 858-626-6362
  • Fax: 858-626-6354
Mailing address:
  • Phone: 858-626-6362
  • Fax: 858-626-6354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberC42394
License Number StateCA

VIII. Authorized Official

Name: FRED J. SIMON JR.
Title or Position: DIRECTOR, MANAGER
Credential: M.D.
Phone: 858-626-6362