Provider Demographics
NPI:1508894304
Name:SIMMONS, CREIGHTON ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:CREIGHTON
Middle Name:ALAN
Last Name:SIMMONS
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 2500
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-2500
Mailing Address - Country:US
Mailing Address - Phone:501-778-2363
Mailing Address - Fax:501-778-5329
Practice Address - Street 1:113 W CARPENTER ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3317
Practice Address - Country:US
Practice Address - Phone:501-778-2363
Practice Address - Fax:501-778-5329
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2383152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U17397Medicare UPIN
AR48290Medicare ID - Type Unspecified