Provider Demographics
NPI:1366053175
Name:ZIMMERMAN, ETHAN (OD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 MOPAC EXPRESSWAY SOUTH, BARTON OAKS PLAZA 4
Mailing Address - Street 2:SUITE 350
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746
Mailing Address - Country:US
Mailing Address - Phone:512-347-0255
Mailing Address - Fax:
Practice Address - Street 1:901 MOPAC EXPRESSWAY SOUTH, BARTON OAKS PLAZA 4
Practice Address - Street 2:SUITE 350
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746
Practice Address - Country:US
Practice Address - Phone:512-347-0255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX10085T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program