Provider Demographics
NPI:1497989396
Name:SIMONICH, MARCUS ANDREW (OD)
Entity Type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:ANDREW
Last Name:SIMONICH
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:PO BOX 1048
Mailing Address - Street 2:8704 DUBAY ROAD
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860
Mailing Address - Country:US
Mailing Address - Phone:406-749-0259
Mailing Address - Fax:
Practice Address - Street 1:417 MAIN ST SW
Practice Address - Street 2:
Practice Address - City:RONAN
Practice Address - State:MT
Practice Address - Zip Code:59864-2738
Practice Address - Country:US
Practice Address - Phone:406-676-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT807152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT807OtherLICENSE NUMBER FOR STATE OF MONTANA