=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477781839
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN DERK ZIMMERMAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2009
-----------------------------------------------------
Last Update Date | 03/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2101 41ST AVE
-----------------------------------------------------
City | LONG ISLAND CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11101-4801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-784-2240
-----------------------------------------------------
Fax | 833-638-0408
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1115 BROADWAY FL 12
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10010-3452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-386-7601
-----------------------------------------------------
Fax | 212-898-0391
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 270222
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------