Active NPI
Samuel Ray Simmons, O.D.
- Optometrist
- Fort Wayne, IN
National Provider Identifier
1295811305
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- 18001933A
- Practice address
- 3411 N Anthony Blvd
Fort Wayne, IN 46805-2233 - Phone
- (260) 482-1707
- Fax
- (260) 482-1707
- NPI assigned
- Oct 31, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 18001933A | IN | Primary |
Addresses
Primary practice location
3411 N Anthony Blvd
Fort Wayne, IN 46805-2233
Mailing address
3411 N Anthony Blvd
Fort Wayne, IN 46805-2233
Phone (260) 482-1707
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 02049 | Other | IN | SPECTERA INSURANCE |
| 135021 | Other | IN | EYEMED INSURANCE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in IN
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20050217000911 | IN | Practitioner - Optometry | 9234181231 | Practice locations: Muncie, IN |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1162252800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183939200000",
"number": "1295811305",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3411 N ANTHONY BLVD",
"city": "FORT WAYNE",
"state": "IN",
"postal_code": "468052233",
"telephone_number": "260-482-1707",
"fax_number": "260-482-1707"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3411 N ANTHONY BLVD",
"city": "FORT WAYNE",
"state": "IN",
"postal_code": "468052233",
"telephone_number": "260-482-1707",
"fax_number": "260-482-1707"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SIMMONS",
"first_name": "SAMUEL",
"middle_name": "RAY",
"credential": "O.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-10-31",
"last_updated": "2007-07-09",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "IN",
"license": "18001933A",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "SPECTERA INSURANCE",
"identifier": "02049",
"state": "IN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "EYEMED INSURANCE",
"identifier": "135021",
"state": "IN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fort Wayne, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.