Active NPI
Laurel L Simon, MD
- Internal Medicine Physician
- Portland, OR
National Provider Identifier
1417024902
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Internal Medicine Physician
- License
- MD 17875
- Practice address
- 4212 NE Broadway St
Portland, OR 97213-1460 - Phone
- (503) 249-8787
- NPI assigned
- Nov 29, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician | 207R00000X | MD 17875 | OR | Primary |
Addresses
Primary practice location
4212 NE Broadway St
Portland, OR 97213-1460
Mailing address
4212 NE Broadway St
Portland, OR 97213-1460
Phone (503) 249-8787
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 06361-0 | Medicaid | OR |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MD 17875 | OR | MD | Internal Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1164758400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1288224000000",
"number": "1417024902",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4212 NE BROADWAY ST",
"city": "PORTLAND",
"state": "OR",
"postal_code": "972131460",
"telephone_number": "503-249-8787"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4212 NE BROADWAY ST",
"city": "PORTLAND",
"state": "OR",
"postal_code": "972131460",
"telephone_number": "503-249-8787"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SIMON",
"first_name": "LAUREL",
"middle_name": "L",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-11-29",
"last_updated": "2010-10-28",
"status": "A"
},
"taxonomies": [
{
"code": "207R00000X",
"taxonomy_group": "",
"desc": "Internal Medicine",
"state": "OR",
"license": "MD 17875",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "06361-0",
"state": "OR"
}
],
"endpoints": [],
"other_names": []
}Other providers in Portland, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 28, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.