Provider Demographics
NPI:1275615775
Name:SIMMONS CLEMMONS, WANDA J (MD)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:J
Last Name:SIMMONS CLEMMONS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6724 GLENKIRK RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-1410
Mailing Address - Country:US
Mailing Address - Phone:443-803-2732
Mailing Address - Fax:
Practice Address - Street 1:6724 GLENKIRK RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-1410
Practice Address - Country:US
Practice Address - Phone:443-900-3184
Practice Address - Fax:410-433-2015
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0035674207QA0505X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD535071900Medicaid
MD535071900Medicaid
MD2268Medicare PIN