Provider Demographics
NPI:1447243464
Name:SIMONS, BRENDA (OD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:
Last Name:SIMONS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 E WEST RD
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-5415
Mailing Address - Country:US
Mailing Address - Phone:708-891-3330
Mailing Address - Fax:708-891-0904
Practice Address - Street 1:1700 E WEST RD
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-5415
Practice Address - Country:US
Practice Address - Phone:708-891-3330
Practice Address - Fax:708-891-0904
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007062152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007062Medicaid
319800Medicare ID - Type Unspecified
IL046007062Medicaid