Provider Demographics
NPI:1114273273
Name:DIMMICK, TODD RYAN (OD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:RYAN
Last Name:DIMMICK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 S BABCOCK ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5356
Mailing Address - Country:US
Mailing Address - Phone:321-725-4755
Mailing Address - Fax:321-725-5088
Practice Address - Street 1:2420 S BABCOCK ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5356
Practice Address - Country:US
Practice Address - Phone:321-725-4755
Practice Address - Fax:321-725-5088
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002688152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOEG002688OtherLICENSE