Provider Demographics
NPI:1588696280
Name:SIMMONS, MARTIN BRUCE (OD)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:BRUCE
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:MARTIN
Other - Middle Name:BRUCE
Other - Last Name:SIMMONS
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:311 W 24TH ST STE 401
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-2667
Mailing Address - Country:US
Mailing Address - Phone:814-455-7591
Mailing Address - Fax:814-454-1467
Practice Address - Street 1:4021 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-2413
Practice Address - Country:US
Practice Address - Phone:937-293-2149
Practice Address - Fax:937-395-9633
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000681152W00000X
OHOPT006726152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1863649OtherKEYSTONE SR BLUE
PA1016403560001Medicaid
PA1315299OtherAETNA HMO
PA180649OtherHIGHMARK BLUE SHIELD
PA1863649OtherKEYSTONE HLTH PLAN CENTRA
PA27541OtherHLTH ASSURANCE
PA5106063OtherAETNA PPO
PA27541OtherHLTH AMERICA
PA1863649OtherCAPITAL BLUE CROSS
PA180649OtherHIGHMARK BLUE SHIELD
PA27541OtherHLTH ASSURANCE