Basic Information
| Provider Information | |||||||||
| NPI: | 1265438691 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIMMONS | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 816 W CANNON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173210404 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4005 24TH ST | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794101835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067922767 | ||||||||
| FaxNumber: | 8888618858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | L1748 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | L1748 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 8G1350 | 01 | TX | BLUE CROSS | OTHER | 1236695 | 01 | FIRST HEALTH | OTHER | 151630401 | 05 | TX | MEDICAID | 300132403 | 01 | RAILROAD MEDICARE | OTHER | 26050561 | 05 | NM | MEDICAID | 128599100 | 01 | TX | FIRSTCARE | OTHER |