Provider Demographics
NPI:1447259981
Name:MADORSKY, SIMON JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:JOSEPH
Last Name:MADORSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6765
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-6765
Mailing Address - Country:US
Mailing Address - Phone:714-571-5000
Mailing Address - Fax:714-571-5055
Practice Address - Street 1:180 NEWPORT CENTER DR
Practice Address - Street 2:158
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-6972
Practice Address - Country:US
Practice Address - Phone:949-719-1800
Practice Address - Fax:949-719-1810
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50075207Y00000X, 207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00002596OtherRAILROAD MEDICARE
P01404246OtherRAILROAD MEDICARE
CA00A500750Medicaid
P00002596OtherRAILROAD MEDICARE
CACB224169Medicare PIN