Provider Demographics
NPI:1710078019
Name:DR MARK M ZIMMER PC
Entity Type:Organization
Organization Name:DR MARK M ZIMMER PC
Other - Org Name:OELWEIN FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:ZIMMER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:319-283-3155
Mailing Address - Street 1:12 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:OELWEIN
Mailing Address - State:IA
Mailing Address - Zip Code:50662-1737
Mailing Address - Country:US
Mailing Address - Phone:319-283-3155
Mailing Address - Fax:319-283-3155
Practice Address - Street 1:12 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:OELWEIN
Practice Address - State:IA
Practice Address - Zip Code:50662-1737
Practice Address - Country:US
Practice Address - Phone:319-283-3155
Practice Address - Fax:319-283-3155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01967152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0419432Medicaid
IA08106OtherBLUE CROSS BLUE SHIELD
IA4078170Medicaid
IA0419432Medicaid
IA4686720002Medicare NSC
IAU20653Medicare UPIN
IAI9236Medicare ID - Type Unspecified