Provider Demographics
NPI:1447444716
Name:THOMAS L SIMMONS
Entity type:Organization
Organization Name:THOMAS L SIMMONS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:LYLE
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-787-3937
Mailing Address - Street 1:741 S 50 W STE B
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455-5345
Mailing Address - Country:US
Mailing Address - Phone:208-787-3937
Mailing Address - Fax:208-787-3939
Practice Address - Street 1:741 S 50 W STE B
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:ID
Practice Address - Zip Code:83455-5129
Practice Address - Country:US
Practice Address - Phone:208-787-3937
Practice Address - Fax:208-787-3939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100009152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID5325290001Medicare NSC
ID1377851Medicare PIN