Provider Demographics
NPI:1467469718
Name:SIMMONS, JONATHAN (OPTOMETRIST)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 W CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:AR
Mailing Address - Zip Code:72360-2212
Mailing Address - Country:US
Mailing Address - Phone:870-295-3636
Mailing Address - Fax:
Practice Address - Street 1:219 W. CHESTNUT
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:AR
Practice Address - Zip Code:72360
Practice Address - Country:US
Practice Address - Phone:870-295-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2390152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119930722Medicaid
AR48355G067OtherMEDICARE GROUP
AR48355G067OtherMEDICARE GROUP
ART69491Medicare UPIN