Provider Demographics
NPI:1396770962
Name:ZISSMAN, JONATHAN ELLIOT (OD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ELLIOT
Last Name:ZISSMAN
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:PO BOX 3976
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-3976
Mailing Address - Country:US
Mailing Address - Phone:970-903-1084
Mailing Address - Fax:
Practice Address - Street 1:190 TALISMAN DR UNIT B4
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-9171
Practice Address - Country:US
Practice Address - Phone:970-731-4347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2532152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist