Provider Demographics
NPI:1801879499
Name:SIMONS, DAVID R (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:SIMONS
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:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:OWYHEE
Mailing Address - State:NV
Mailing Address - Zip Code:89832-0130
Mailing Address - Country:US
Mailing Address - Phone:775-757-2415
Mailing Address - Fax:
Practice Address - Street 1:1550 BASELINE RD
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-7651
Practice Address - Country:US
Practice Address - Phone:303-443-4919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22166207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01221662Medicaid
COD24043Medicare UPIN
COCM0278Medicare PIN
COM0278Medicare ID - Type Unspecified
CO080079039Medicare PIN