Provider Demographics
NPI:1023132420
Name:SIMMONS, ERIC A (DO)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:A
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:DO
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 4656
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-4656
Mailing Address - Country:US
Mailing Address - Phone:208-376-1611
Mailing Address - Fax:208-658-1753
Practice Address - Street 1:335 ALLUMBAUGH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9208
Practice Address - Country:US
Practice Address - Phone:208-376-1611
Practice Address - Fax:208-658-1753
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0-3002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010146503OtherBLUE SHIELD INDIVIDUAL
ID806503100Medicaid
IDS4802OtherBLUE CROSS INDIVIDUAL
ID000010146503OtherBLUE SHIELD INDIVIDUAL
ID806503100Medicaid