Provider Demographics
NPI:1811092760
Name:SIMMONS, MARK STUART (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:STUART
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6531 W. ANTLER BEND PL
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85658
Mailing Address - Country:US
Mailing Address - Phone:970-213-8123
Mailing Address - Fax:970-266-3660
Practice Address - Street 1:3870 W. RIVER RD
Practice Address - Street 2:#126
Practice Address - City:TUSCON
Practice Address - State:AZ
Practice Address - Zip Code:85741
Practice Address - Country:US
Practice Address - Phone:520-219-6616
Practice Address - Fax:970-266-3660
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37923207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO81353871Medicaid
CO110198245OtherRR MEDICARE PIN
CO81353871Medicaid
CO341938YLB8Medicare PIN
COG25978Medicare UPIN
CO110198245Medicare PIN