Healthcare Provider Details

I. General information

NPI: 1114244175
Provider Name (Legal Business Name): PETER JOHN SIMON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 PARNASSUS AVE
SAN FRANCISCO CA
94143-2204
US

IV. Provider business mailing address

11 DOLORES ST APT 2
SAN FRANCISCO CA
94103-1061
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-5001
  • Fax:
Mailing address:
  • Phone: 650-296-4143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: