Provider Demographics
NPI:1003577818
Name:SIMMONS, JOHN W II (PRESIDENT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:W
Last Name:SIMMONS
Suffix:II
Gender:M
Credentials:PRESIDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 JOHNSON PL
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-5930
Mailing Address - Country:US
Mailing Address - Phone:917-549-6504
Mailing Address - Fax:516-992-2637
Practice Address - Street 1:4 JOHNSON PL
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-5930
Practice Address - Country:US
Practice Address - Phone:917-549-6504
Practice Address - Fax:516-992-2637
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver