Provider Demographics
NPI:1972579829
Name:SIMMONS, PHILIP LEE (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:LEE
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT LA 21693
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1693
Mailing Address - Country:US
Mailing Address - Phone:858-564-1400
Mailing Address - Fax:858-564-1500
Practice Address - Street 1:36320 INLAND VALLEY DR
Practice Address - Street 2:STE 101
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-7512
Practice Address - Country:US
Practice Address - Phone:951-600-3811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG811302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G811300OtherBCBS
CA00G811300Medicaid
CA300098798Medicare PIN
CA00G811300Medicare PIN
CA00G811300Medicaid