=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376514646
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK ZIMMERMAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2006
-----------------------------------------------------
Last Update Date | 06/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5967 SUN APPELLO AVE
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89122-3447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-489-5120
-----------------------------------------------------
Fax | 702-489-5120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5967 SUN APPELLO AVE
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89122-3447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-489-5120
-----------------------------------------------------
Fax | 702-489-5120
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 97-414
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------