Provider Demographics
NPI:1003909482
Name:SIMMONS, BLAKE G (OD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:G
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:320 E FONTANERO ST STE 201
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-7525
Mailing Address - Country:US
Mailing Address - Phone:719-559-2020
Mailing Address - Fax:719-623-6088
Practice Address - Street 1:320 E FONTANERO ST STE 201
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-7525
Practice Address - Country:US
Practice Address - Phone:719-559-2020
Practice Address - Fax:719-623-6088
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1756152W00000X
COOPT-2588152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist