Provider Demographics
NPI:1205890027
Name:WILCOX, SIMMON L (MD)
Entity type:Individual
Prefix:
First Name:SIMMON
Middle Name:L
Last Name:WILCOX
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 1:6421 ABERDEEN LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-1268
Mailing Address - Country:US
Mailing Address - Phone:702-415-9906
Mailing Address - Fax:866-383-4399
Practice Address - Street 1:4550 E CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-5525
Practice Address - Country:US
Practice Address - Phone:702-415-9906
Practice Address - Fax:866-383-4399
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033724E207QA0505X
NV11588207QA0505X, 208VP0000X
UT6968998-1205207QA0505X
MO2009007880207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000185023OtherHIGHMARK BC/BS
NV100510116Medicaid
PAA60333Medicare UPIN
PA000185023OtherHIGHMARK BC/BS
NV104740Medicare PIN