Simon Daniel Xavier Thebault, M.D.

Primary specialty

Neurology PhysicianTaxonomy code 2084N0400X

License

MD478091 Issued in PA

Practice address

3400 Civic Center Blvd S
2ND Floor
Philadelphia, PA 19104

Phone

(215) 316-5151

NPI assigned

Jul 21, 2022

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1658361600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1664323200000",
    "number": "1174258305",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "24 CRICKET AVE",
            "address_2": "APT 408",
            "city": "ARDMORE",
            "state": "PA",
            "postal_code": "19003",
            "telephone_number": "267-588-2244"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3400 CIVIC CENTER BLVD S",
            "address_2": "2ND FLOOR",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "19104",
            "telephone_number": "215-316-5151"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "THEBAULT",
        "first_name": "SIMON",
        "middle_name": "DANIEL XAVIER",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2022-07-21",
        "last_updated": "2022-09-28",
        "certification_date": "2022-09-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084N0400X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": "PA",
            "license": "MD478091",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Theodore B Porter, DO, PC

• Neurology Physician in Philadelphia, PA
• Providers in Philadelphia, PA by specialty
• Neurology Physician in Pennsylvania

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 28, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.