Provider Demographics
NPI:1922748961
Name:ZIMMERMAN, LACEY (MD)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:SOLOMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:820 SOUTH WOOD ST
Mailing Address - Street 2:SUITE 100, MC 675
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612
Mailing Address - Country:US
Mailing Address - Phone:312-996-2933
Mailing Address - Fax:
Practice Address - Street 1:820 SOUTH WOOD ST
Practice Address - Street 2:SUITE 100, MC 675
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-996-2933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.080041207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program