Provider Demographics
NPI:1578779195
Name:SIMONSON, TIM
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:SIMONSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1192 W PHEASANT RUN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-2515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 N ARTHUR ST
Practice Address - Street 2:
Practice Address - City:HUMANSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65674-8655
Practice Address - Country:US
Practice Address - Phone:417-754-2208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004253174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist