Healthcare Provider Details

I. General information

NPI: 1144458217
Provider Name (Legal Business Name): DAGOBERT SIMO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 MADISON PARK DR
GLEN BURNIE MD
21061-6189
US

IV. Provider business mailing address

5111 HONEY LOCUST CT
ELLICOTT CITY MD
21042-6016
US

V. Phone/Fax

Practice location:
  • Phone: 410-487-6902
  • Fax: 410-487-6982
Mailing address:
  • Phone: 410-487-6902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberD0073466
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0073466
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: