Provider Demographics
NPI:1073555793
Name:MARC S. SIMMONS, O.D., INC.
Entity Type:Organization
Organization Name:MARC S. SIMMONS, O.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:S
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-674-5123
Mailing Address - Street 1:6225 W 87TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3979
Mailing Address - Country:US
Mailing Address - Phone:310-674-5123
Mailing Address - Fax:310-674-1966
Practice Address - Street 1:6225 W 87TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3979
Practice Address - Country:US
Practice Address - Phone:310-674-5123
Practice Address - Fax:310-674-1966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7057T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0070570Medicaid
CAT70169Medicare UPIN
CA4964210001Medicare NSC
CASD0070570Medicaid