Provider Demographics
NPI:1164973699
Name:SIMMONS, TIMOTHY SR
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:SIMMONS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 WATERLOO DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-4822
Mailing Address - Country:US
Mailing Address - Phone:317-250-2068
Mailing Address - Fax:317-291-0423
Practice Address - Street 1:3420 WATERLOO DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-4822
Practice Address - Country:US
Practice Address - Phone:317-250-2068
Practice Address - Fax:317-291-0423
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0290023440343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)