Healthcare Provider Details

I. General information

NPI: 1205890027
Provider Name (Legal Business Name): SIMMON L WILCOX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 02/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 E CHARLESTON BLVD
LAS VEGAS NV
89104-5525
US

IV. Provider business mailing address

6421 ABERDEEN LN
LAS VEGAS NV
89107-1268
US

V. Phone/Fax

Practice location:
  • Phone: 702-415-9906
  • Fax: 866-383-4399
Mailing address:
  • Phone: 702-415-9906
  • Fax: 866-383-4399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberMD033724E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number11588
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number6968998-1205
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2009007880
License Number StateMO
# 5
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number11588
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: