Healthcare Provider Details

I. General information

NPI: 1376806554
Provider Name (Legal Business Name): SIMON MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 10/19/2024
Certification Date: 10/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 W FLAGLER ST STE 420
MIAMI FL
33174-2546
US

IV. Provider business mailing address

PO BOX 831975
MIAMI FL
33283-1975
US

V. Phone/Fax

Practice location:
  • Phone: 305-608-0656
  • Fax: 786-254-7084
Mailing address:
  • Phone: 305-608-0656
  • Fax: 786-254-7084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberME112149
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME112149
License Number StateFL

VIII. Authorized Official

Name: DR. JOSE MIGUEL SIMON CANELLAS
Title or Position: PRESIDENT
Credential: MD
Phone: 305-608-0656