Basic Information
Provider Information | |||||||||
NPI: | 1710176896 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JOHN V. SIMONS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1900 MALVERN AVE | ||||||||
Address2: | SUITE 203 | ||||||||
City: | HOT SPRINGS | ||||||||
State: | AR | ||||||||
PostalCode: | 71901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5013212444 | ||||||||
FaxNumber: | 5013219521 | ||||||||
Practice Location | |||||||||
Address1: | 1900 MALVERN AVE | ||||||||
Address2: | SUITE 203 | ||||||||
City: | HOT SPRINGS | ||||||||
State: | AR | ||||||||
PostalCode: | 71901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5013212444 | ||||||||
FaxNumber: | 5013219521 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/15/2007 | ||||||||
LastUpdateDate: | 10/15/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SIMONS | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | V | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN/ OWNER | ||||||||
AuthorizedOfficialTelephone: | 5013212444 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.P.M. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 82 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
ID Information
ID | Type | State | Issuer | Description | 56428 | 01 | AR | MEDICARE PROVIDER NUMBER | OTHER |