Healthcare Provider Details

I. General information

NPI: 1407925100
Provider Name (Legal Business Name): CARL MICHAEL SIMONE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N MADISON ST
ROCKFORD IL
61107-3949
US

IV. Provider business mailing address

121 N MADISON ST
ROCKFORD IL
61107-3949
US

V. Phone/Fax

Practice location:
  • Phone: 815-963-3454
  • Fax: 815-963-4384
Mailing address:
  • Phone: 815-963-3454
  • Fax: 815-963-4384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: