Provider Demographics
NPI:1265846703
Name:TIMMERMANN, FELICIA JEAN (OD)
Entity Type:Individual
Prefix:
First Name:FELICIA
Middle Name:JEAN
Last Name:TIMMERMANN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE # 8096
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-747-5380
Mailing Address - Fax:314-362-5590
Practice Address - Street 1:3200 S UNIVERSITY DR BLDG 2
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:954-262-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5452152W00000X
MO2017031245152W00000X
IL046010899152W00000X
OH6326152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010899Medicaid
IL046010899Medicaid