Provider Demographics
NPI:1588158174
Name:SIMMONS, KATINA (OD)
Entity type:Individual
Prefix:
First Name:KATINA
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRISWOLD
Mailing Address - State:CT
Mailing Address - Zip Code:06351-2012
Mailing Address - Country:US
Mailing Address - Phone:860-376-2848
Mailing Address - Fax:860-376-4821
Practice Address - Street 1:8 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GRISWOLD
Practice Address - State:CT
Practice Address - Zip Code:06351-2012
Practice Address - Country:US
Practice Address - Phone:860-376-2848
Practice Address - Fax:860-376-4821
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3073152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT3073OtherSTATE LICENSE