Healthcare Provider Details

I. General information

NPI: 1225089709
Provider Name (Legal Business Name): KENNETH SIMONS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 01/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 N 87TH ST THE EYE INSTITUTE
MILWAUKEE WI
53226-4812
US

IV. Provider business mailing address

925 N 87TH ST THE EYE INSTITUTE
MILWAUKEE WI
53226-4812
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-2020
  • Fax: 414-955-6332
Mailing address:
  • Phone: 414-955-2020
  • Fax: 414-955-6332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number30163
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number30163
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: