Provider Demographics
NPI:1366772139
Name:SIMONE, MARIA VALERIA (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:VALERIA
Last Name:SIMONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VALERIA
Other - Middle Name:MARIA
Other - Last Name:SIMONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1545 E SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6422
Mailing Address - Country:US
Mailing Address - Phone:817-748-0200
Mailing Address - Fax:817-749-0204
Practice Address - Street 1:1545 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6422
Practice Address - Country:US
Practice Address - Phone:817-748-0200
Practice Address - Fax:817-749-0204
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-30
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ7602208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3203798Medicaid
NY3203798Medicaid