Provider Demographics
NPI:1689670598
Name:ZIMMER, MARK M (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:ZIMMER
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 1:216 2ND ST NE
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:IA
Mailing Address - Zip Code:50644-1910
Mailing Address - Country:US
Mailing Address - Phone:319-334-3631
Mailing Address - Fax:319-334-3631
Practice Address - Street 1:216 2ND ST NE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:IA
Practice Address - Zip Code:50644-1910
Practice Address - Country:US
Practice Address - Phone:319-334-3631
Practice Address - Fax:319-334-3631
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1967152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0419432Medicaid
IAP00000678OtherRAILROAD MEDICARE
IA06297OtherBLUE CROSS & BLUE SHIELD
IA08106OtherBCBS FOR OELWEIN
IA43738OtherBCBS
IA0419424Medicaid
IA0419432Medicaid
IA08106OtherBCBS FOR OELWEIN
IAI9234Medicare ID - Type Unspecified
IAI9236Medicare ID - Type UnspecifiedMEDICARE FOR OELWEIN