Provider Demographics
NPI:1184682577
Name:ZIMMERMAN, ANDREW W (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:W
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:PEDIATRIC NEUROLOGY
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:774-442-5695
Practice Address - Fax:508-856-4287
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA216753208000000X, 2080P0008X, 2084N0402X, 2080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110033314AMedicaid
MAS400104406OtherMEDICARE
MA001802001Medicare PIN
MDA97157Medicare UPIN
MDKR37058MMedicare PIN