Provider Demographics
NPI:1366429581
Name:SIMON, KATIE LEE (OD)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:LEE
Last Name:SIMON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6483 S WESTNEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-3542
Mailing Address - Country:US
Mailing Address - Phone:269-324-4242
Mailing Address - Fax:
Practice Address - Street 1:6483 S WESTNEDGE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-3542
Practice Address - Country:US
Practice Address - Phone:269-324-4242
Practice Address - Fax:269-324-6145
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004118152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4551220Medicaid
MIN97810005Medicare ID - Type Unspecified
MI4551220Medicaid