Basic Information
| Provider Information | |||||||||
| NPI: | 1366437758 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZIMMER | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11725 STINSON AVE | ||||||||
| Address2: | |||||||||
| City: | CHISAGO CITY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550139542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512578421 | ||||||||
| FaxNumber: | 6512578464 | ||||||||
| Practice Location | |||||||||
| Address1: | 11725 STINSON AVE | ||||||||
| Address2: | |||||||||
| City: | CHISAGO CITY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550139542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512578421 | ||||||||
| FaxNumber: | 6512578464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 11/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1672 | MN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 424323400 | 05 | MN | MEDICAID |