Healthcare Provider Details

I. General information

NPI: 1073784534
Provider Name (Legal Business Name): JOCK SIMON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30686 SATTERFIELD CT
SALISBURY MD
21804-2365
US

IV. Provider business mailing address

30686 SATTERFIELD CT
SALISBURY MD
21804-2365
US

V. Phone/Fax

Practice location:
  • Phone: 410-742-3204
  • Fax:
Mailing address:
  • Phone: 410-742-3204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD0028257
License Number StateMD

VIII. Authorized Official

Name: DR. JOCK SIMON
Title or Position: OWNER
Credential: MD
Phone: 410-742-8204