Provider Demographics
NPI:1235392598
Name:SIMMONS, JUSTIN (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4069 LAKE DR SE
Practice Address - Street 2:SUITE 312
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8816
Practice Address - Country:US
Practice Address - Phone:616-267-8700
Practice Address - Fax:616-267-8247
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101017740208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery