Provider Demographics
NPI:1285661603
Name:SIMMONS, K BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:K
Middle Name:BRUCE
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 PRESIDENTIAL PLZ
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-2240
Mailing Address - Country:US
Mailing Address - Phone:315-464-3850
Mailing Address - Fax:315-464-3872
Practice Address - Street 1:90 PRESIDENTIAL PLZ
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2240
Practice Address - Country:US
Practice Address - Phone:315-464-3850
Practice Address - Fax:315-464-3872
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149810207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00730772Medicaid
NY37221PMedicare PIN
NYP110061800Medicare PIN