Provider Demographics
NPI:1316243439
Name:SIMMONS, MARK DOUGLAS (PT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DOUGLAS
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 N COUNTY ROAD 20 W
Mailing Address - Street 2:CEDAR KNOLL FARMS
Mailing Address - City:NORTH VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47265-8202
Mailing Address - Country:US
Mailing Address - Phone:812-801-1362
Mailing Address - Fax:
Practice Address - Street 1:2560 N COUNTY ROAD 20 W
Practice Address - Street 2:
Practice Address - City:NORTH VERNON
Practice Address - State:IN
Practice Address - Zip Code:47265-8202
Practice Address - Country:US
Practice Address - Phone:812-801-1362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002822A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN05002822AOtherINDIANA PROFESSIONAL LICENSING AGENCY PHYSICAL THERAPY