Provider Demographics
NPI:1790773737
Name:SIMMONS, LISA J (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3850 S NATIONAL AVE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5287
Mailing Address - Country:US
Mailing Address - Phone:417-882-4880
Mailing Address - Fax:417-882-7843
Practice Address - Street 1:3850 S NATIONAL AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5287
Practice Address - Country:US
Practice Address - Phone:417-882-4880
Practice Address - Fax:417-882-7843
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33840207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP00687435OtherRR MEDICARE
IA1790773737Medicaid
IA2226035Medicaid
36328OtherWELLMARK BCBS
IA1790773737Medicaid
IAI12429Medicare PIN
H32697Medicare UPIN
IAP00687435OtherRR MEDICARE