Provider Demographics
NPI:1740247311
Name:SIMMONS, DWELVIN L (MD)
Entity type:Individual
Prefix:
First Name:DWELVIN
Middle Name:L
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:2161 KINGSLEY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5116
Practice Address - Country:US
Practice Address - Phone:904-276-2303
Practice Address - Fax:904-276-9690
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME779362085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258515OtherAVMED
FL7884043OtherAETNA
FL7638449OtherCIGNA
FL1099111OtherWELLCARE
FL256841100Medicaid
FLP01451925OtherRR MEDICARE
FLP00202470OtherMEDICARE RAILROAD
FLP01596543OtherRR MEDICARE
FL1254570OtherSTAYWELL (MEDICAID) AND WELLCARE (MEDICARE).
FL1115826OtherCARE PLUS
FL68967OtherBCBS
FL1254570OtherSTAYWELL (MEDICAID) AND WELLCARE (MEDICARE).
FLCZ876RMedicare PIN
FL68967OMedicare PIN
FL68967LMedicare PIN
FLCZ876ZMedicare PIN
FL68967UMedicare PIN
FL256841100Medicaid
FLCZ876TMedicare PIN
FLCZ876VMedicare PIN
FL68967NMedicare PIN
FLCZ876QMedicare PIN
FLG91262Medicare UPIN
FL68967MMedicare PIN
FLCZ876YMedicare PIN
FL7638449OtherCIGNA