Provider Demographics
NPI:1407925100
Name:SIMONE, CARL MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:MICHAEL
Last Name:SIMONE
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 1:121 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3949
Mailing Address - Country:US
Mailing Address - Phone:815-963-3454
Mailing Address - Fax:815-963-4384
Practice Address - Street 1:121 N MADISON ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3949
Practice Address - Country:US
Practice Address - Phone:815-963-3454
Practice Address - Fax:815-963-4384
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
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
IL08123272OtherBCBS
IL622280Medicare ID - Type Unspecified
IL08123272OtherBCBS