Provider Demographics
NPI:1053310029
Name:SIMONS, DAVID R I (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:SIMONS
Suffix:I
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 OSOLO RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-4122
Mailing Address - Country:US
Mailing Address - Phone:574-523-3347
Mailing Address - Fax:574-206-9502
Practice Address - Street 1:1506 OSOLO RD
Practice Address - Street 2:SUITE A
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-4122
Practice Address - Country:US
Practice Address - Phone:574-523-3347
Practice Address - Fax:574-206-9502
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040248A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000184549OtherANTHEM
IN09542OtherCIGNA
IN100092420Medicaid
IN0004274508OtherAETNA
IN000000283879OtherANTHEM BCBS
IN000000184549OtherUNICARE
IN6800161822Medicare PIN
IN148460AMedicare PIN
141580BMedicare PIN
IN0004274508OtherAETNA
R33393Medicare UPIN