Provider Demographics
NPI:1417937673
Name:SIMMONS, CAROLYN ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:ELIZABETH
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:SIMMONS-RANCOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2371 NE STEPHENS ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1399
Mailing Address - Country:US
Mailing Address - Phone:541-672-8533
Mailing Address - Fax:
Practice Address - Street 1:480 WARTAHOO LN
Practice Address - Street 2:
Practice Address - City:CANYONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97417-9683
Practice Address - Country:US
Practice Address - Phone:541-839-1345
Practice Address - Fax:855-670-1791
Is Sole Proprietor?:No
Enumeration Date:2006-01-21
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60385919207Q00000X
NV9151207Q00000X
ORMD170122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9151OtherNEVADA STATE BOARD OF MED
NV20-16738Medicaid
ORMD170122OtherOREGON MEDICAL BOARD
NVCS09655OtherNV BOARD OF PHARMACY
WAMD60385919OtherWASHINGTON STATE DEPARTMENT OF HEALTH
NV20-16738Medicaid
V36006Medicare PIN