1689670598 NPI number — DR. MARK M ZIMMER OD

Table of content: DR. MARK M ZIMMER OD (NPI 1689670598)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689670598 NPI number — DR. MARK M ZIMMER OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ZIMMER
Provider First Name:
MARK
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689670598
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
216 2ND ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDEPENDENCE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50644-1910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-334-3631
Provider Business Mailing Address Fax Number:
319-334-3631

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
216 2ND ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50644-1910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-334-3631
Provider Business Practice Location Address Fax Number:
319-334-3631
Provider Enumeration Date:
06/24/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1967 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0419432 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00000678 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 06297 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 08106 . This is a "BCBS FOR OELWEIN" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 43738 . This is a "BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0419424 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".