Healthcare Provider Details

I. General information

NPI: 1942810726
Provider Name (Legal Business Name): SCOTT DAVID SIMON MD FACS MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9834 GENESEE AVE STE 416
LA JOLLA CA
92037-1264
US

IV. Provider business mailing address

9834 GENESEE AVE STE 416
LA JOLLA CA
92037-1264
US

V. Phone/Fax

Practice location:
  • Phone: 858-307-6585
  • Fax: 858-309-6593
Mailing address:
  • Phone: 858-307-6585
  • Fax: 858-309-6593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT D SIMON
Title or Position: PRESIDENT
Credential: MD
Phone: 858-307-6585