Healthcare Provider Details

I. General information

NPI: 1316265259
Provider Name (Legal Business Name): MELISSA ANN SIMON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2010
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOPPIN ST STE 202
PROVIDENCE RI
02903-4141
US

IV. Provider business mailing address

2 DUDLEY ST STE 505
PROVIDENCE RI
02905-3249
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-6551
  • Fax:
Mailing address:
  • Phone: 401-444-7008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number161664
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number14710
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: