1053310029 NPI number — DR. DAVID R. SIMONS I PHD

Table of content: DR. DAVID R. SIMONS I PHD (NPI 1053310029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053310029 NPI number — DR. DAVID R. SIMONS I PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMONS
Provider First Name:
DAVID
Provider Middle Name:
R.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
I
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053310029
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1506 OSOLO RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
ELKHART
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46514-4122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-523-3347
Provider Business Mailing Address Fax Number:
574-206-9502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1506 OSOLO RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ELKHART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46514-4122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-523-3347
Provider Business Practice Location Address Fax Number:
574-206-9502
Provider Enumeration Date:
07/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  20040248A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000184549 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 09542 . This is a "CIGNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100092420 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0004274508 . This is a "AETNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000283879 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000184549 . This is a "UNICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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