Healthcare Provider Details

I. General information

NPI: 1336189075
Provider Name (Legal Business Name): JON L SIMMONS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 ROOSEVELT ROAD
MARINETTE WI
54143-3834
US

IV. Provider business mailing address

PO BOX 1866
GREEN BAY WI
54305-1866
US

V. Phone/Fax

Practice location:
  • Phone: 715-735-5225
  • Fax: 715-735-5388
Mailing address:
  • Phone: 920-445-7222
  • Fax: 920-445-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37092
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number4301089159
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: