Provider Demographics
NPI:1831218031
Name:SIMON, NAOMI SOROOSH (MD)
Entity type:Individual
Prefix:DR
First Name:NAOMI
Middle Name:SOROOSH
Last Name:SIMON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-1845
Mailing Address - Country:US
Mailing Address - Phone:704-235-1827
Mailing Address - Fax:704-235-1823
Practice Address - Street 1:128 MEDICAL PARK RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8578
Practice Address - Country:US
Practice Address - Phone:704-235-1827
Practice Address - Fax:704-235-1823
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-00134207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5914416Medicaid
NC2023425AMedicare PIN
NC5914416Medicaid