Healthcare Provider Details

I. General information

NPI: 1821069311
Provider Name (Legal Business Name): KEITH A SIMON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 ROSE AVE VENICE FAMILY CLINIC/OPTOMETRY DEPT.
VENICE CA
90291-2767
US

IV. Provider business mailing address

PO BOX 57624
SHERMAN OAKS CA
91413-2624
US

V. Phone/Fax

Practice location:
  • Phone: 310-392-8636
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10592 TPG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: