Provider Demographics
NPI:1154626430
Name:SIMMONS, JOHN WALTON SR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WALTON
Last Name:SIMMONS
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 E MAIN ST
Mailing Address - Street 2:SUITE 14 BOX 6
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-2309
Mailing Address - Country:US
Mailing Address - Phone:864-266-7164
Mailing Address - Fax:
Practice Address - Street 1:4245 CLIFTON GLENDALE RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-3409
Practice Address - Country:US
Practice Address - Phone:864-266-7164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5819207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine