Healthcare Provider Details

I. General information

NPI: 1154581882
Provider Name (Legal Business Name): LAWRENCE MARIANO SIMON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3256 HIGHWAY 190
EUNICE LA
70535-5125
US

IV. Provider business mailing address

3256 HIGHWAY 190
EUNICE LA
70535-5125
US

V. Phone/Fax

Practice location:
  • Phone: 337-550-8530
  • Fax: 337-550-8534
Mailing address:
  • Phone: 337-550-8530
  • Fax: 337-550-8534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberMD.203465
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: