Provider Demographics
NPI:1730125188
Name:SIMMONS, MARC S (OD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:S
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 1:6225 W 87TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3979
Mailing Address - Country:US
Mailing Address - Phone:310-674-5123
Mailing Address - Fax:310-674-1966
Practice Address - Street 1:6225 W 87TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3979
Practice Address - Country:US
Practice Address - Phone:310-674-5123
Practice Address - Fax:310-674-1966
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7057T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0070570Medicaid
CASD0070570Medicaid
T70169Medicare UPIN