Provider Demographics
NPI:1548397854
Name:ZIMMERMAN, ROBERT (OPHTHALMIC DISPENSER)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:OPHTHALMIC DISPENSER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 LINCOLN PLACE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217
Mailing Address - Country:US
Mailing Address - Phone:718-768-2553
Mailing Address - Fax:
Practice Address - Street 1:167 LINCOLN PLACE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217
Practice Address - Country:US
Practice Address - Phone:718-768-2553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005287-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01521360Medicaid