Provider Demographics
NPI:1295811305
Name:SIMMONS, SAMUEL RAY (OD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:RAY
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 1:3411 N ANTHONY BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-2233
Mailing Address - Country:US
Mailing Address - Phone:260-482-1707
Mailing Address - Fax:260-482-1707
Practice Address - Street 1:3411 N ANTHONY BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-2233
Practice Address - Country:US
Practice Address - Phone:260-482-1707
Practice Address - Fax:260-482-1707
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001933A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN02049OtherSPECTERA INSURANCE
IN135021OtherEYEMED INSURANCE
INU25093Medicare UPIN
IN135021OtherEYEMED INSURANCE