Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | TEMPORARY | TX |
NPI | 1295710820 |
---|---|
Provider Name | Dr. Stephen D. Simonich |
First Address | Tomball, TX 77375-6410 |
Second Address | Tomball, TX 77375-6410 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/12/2005 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H49431 | (02) | TX |