Healthcare Provider Details

I. General information

NPI: 1073502993
Provider Name (Legal Business Name): KENNETH M SIMON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 08/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4255 BOY SCOUT CAMP
NEW SMYRNA BEACH FL
32168-8896
US

IV. Provider business mailing address

4255 BOY SCOUT ROAD
NEW SMYRNA BEACH FL
32168
US

V. Phone/Fax

Practice location:
  • Phone: 386-478-1977
  • Fax:
Mailing address:
  • Phone: 386-478-1977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberOS7658
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: