Provider Demographics
NPI:1083754741
Name:SIMMERMAN, JERRELL S (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRELL
Middle Name:S
Last Name:SIMMERMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 MEDICAL CT
Mailing Address - Street 2:STE C
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-4833
Mailing Address - Country:US
Mailing Address - Phone:317-848-4041
Mailing Address - Fax:
Practice Address - Street 1:301 E CARMEL DR
Practice Address - Street 2:BUILDING F, SUITE 300
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2888
Practice Address - Country:US
Practice Address - Phone:317-848-4041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002063B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN312450Medicare PIN
INT34669Medicare UPIN