Provider Demographics
NPI:1902809825
Name:SIMMONS, MELITTA (DPM)
Entity Type:Individual
Prefix:
First Name:MELITTA
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-1581
Mailing Address - Country:US
Mailing Address - Phone:937-599-3668
Mailing Address - Fax:937-599-4852
Practice Address - Street 1:2330 E HIGH ST UNIT B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-1371
Practice Address - Country:US
Practice Address - Phone:614-866-3182
Practice Address - Fax:614-866-5627
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003322213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2406668Medicaid
U98199Medicare UPIN