Provider Demographics
NPI:1407101892
Name:SIMMONS, KEVIN MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:KEVY
Other - Middle Name:MICHAEL
Other - Last Name:SIMMONS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:2180 TROOP DR
Mailing Address - Street 2:APT D104
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4563
Mailing Address - Country:US
Mailing Address - Phone:320-258-3915
Mailing Address - Fax:320-258-3917
Practice Address - Street 1:14645 BEL RED RD
Practice Address - Street 2:BUILDING E, STE 102
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3929
Practice Address - Country:US
Practice Address - Phone:425-432-6056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN3454152W00000X, 152WV0400X, 152WP0200X
WAOD60294819152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy