Healthcare Provider Details

I. General information

NPI: 1881784585
Provider Name (Legal Business Name): RODNEY L. IMMERMAN, O.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CROWN COLONY DR SUITE 301
QUINCY MA
02169-0931
US

IV. Provider business mailing address

389 CANTON AVE
MILTON MA
02186-3332
US

V. Phone/Fax

Practice location:
  • Phone: 617-770-4400
  • Fax: 617-471-5093
Mailing address:
  • Phone: 617-698-6700
  • Fax: 617-698-5123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberMA3103
License Number StateMA

VIII. Authorized Official

Name: DR. RODNEY LANE IMMERMAN
Title or Position: OWNER
Credential: O.D.
Phone: 617-698-6700