Provider Demographics
NPI:1184676967
Name:SIMMONS, ROBERT LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEE
Last Name:SIMMONS
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 1:333 CHICAGO AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAVANNA
Mailing Address - State:IL
Mailing Address - Zip Code:61074
Mailing Address - Country:US
Mailing Address - Phone:815-273-2422
Mailing Address - Fax:815-273-5034
Practice Address - Street 1:333 CHICAGO AVENUE
Practice Address - Street 2:
Practice Address - City:SAVANNA
Practice Address - State:IL
Practice Address - Zip Code:61074
Practice Address - Country:US
Practice Address - Phone:815-273-2422
Practice Address - Fax:815-273-2422
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0000884001OtherBC/BS
ILK11930Medicare PIN
ILT01004Medicare UPIN