=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285700153
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR MARK M ZIMMER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2006
-----------------------------------------------------
Last Update Date | 11/26/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 216 2ND ST NE
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50644-1910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-334-3631
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 216 2ND ST NE
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50644-1910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-334-3631
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARK MATTHEW ZIMMER II
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 319-444-2126
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 01967
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------