Provider Demographics
NPI:1043364649
Name:SIMON, BENNETT (MD)
Entity type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:
Last Name:SIMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44B BURROUGHS ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4016
Mailing Address - Country:US
Mailing Address - Phone:617-983-8733
Mailing Address - Fax:617-983-1877
Practice Address - Street 1:44B BURROUGHS ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-4016
Practice Address - Country:US
Practice Address - Phone:617-983-8733
Practice Address - Fax:617-983-1877
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA331082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MASIB11362OtherBLUE CROSS BLUE SHIELD