Provider Demographics
NPI:1669726840
Name:SIMMONS, JOE LOUIS (RPH)
Entity type:Individual
Prefix:MR
First Name:JOE
Middle Name:LOUIS
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4735 E LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76103-3835
Mailing Address - Country:US
Mailing Address - Phone:817-413-0545
Mailing Address - Fax:817-413-0570
Practice Address - Street 1:4735 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-3835
Practice Address - Country:US
Practice Address - Phone:817-413-0545
Practice Address - Fax:817-413-0570
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28297261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center