Basic Information
| Provider Information | |||||||||
| NPI: | 1740247311 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIMMONS | ||||||||
| FirstName: | DWELVIN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2234 COLONIAL BLVD | ||||||||
| Address2: | ATTN: PAYER CONTRACTING & RELATIONS DEPT. | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Practice Location | |||||||||
| Address1: | 2161 KINGSLEY AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320735116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042762303 | ||||||||
| FaxNumber: | 9042769690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 02/01/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | ME77936 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 258515 | 01 | FL | AVMED | OTHER | 7884043 | 01 | FL | AETNA | OTHER | 7638449 | 01 | FL | CIGNA | OTHER | 1099111 | 01 | FL | WELLCARE | OTHER | 256841100 | 05 | FL | MEDICAID | P01451925 | 01 | FL | RR MEDICARE | OTHER | P00202470 | 01 | FL | MEDICARE RAILROAD | OTHER | P01596543 | 01 | FL | RR MEDICARE | OTHER | 1254570 | 01 | FL | STAYWELL (MEDICAID) AND WELLCARE (MEDICARE). | OTHER | 1115826 | 01 | FL | CARE PLUS | OTHER | 68967 | 01 | FL | BCBS | OTHER |