Healthcare Provider Details

I. General information

NPI: 1083786024
Provider Name (Legal Business Name): JACK HOWARD SIMON M.D.,PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JACK HOWARD SIMON MD,PH.D.

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 SW VETERANS HOSPITAL RD PORTLAND VA MEDICAL CENTER
PORTLAND OR
97207
US

IV. Provider business mailing address

PO BOX 3980
WILSONVILLE OR
97070-1540
US

V. Phone/Fax

Practice location:
  • Phone: 303-819-2848
  • Fax:
Mailing address:
  • Phone: 303-819-2848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number23522
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number23522
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: