Provider Demographics
NPI:1528055068
Name:IMMERMAN, RODNEY L (OD)
Entity type:Individual
Prefix:
First Name:RODNEY
Middle Name:L
Last Name:IMMERMAN
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 1:13 FORT ST
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-2757
Mailing Address - Country:US
Mailing Address - Phone:617-698-6700
Mailing Address - Fax:
Practice Address - Street 1:1900 CROWN COLONY DR
Practice Address - Street 2:SUITE 301
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-0979
Practice Address - Country:US
Practice Address - Phone:617-698-6700
Practice Address - Fax:617-698-5123
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3103152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW20420OtherBCBS GROUP
MA763497OtherTUFTS
MAW15692OtherBCBS
MA158263OtherHPHC
MA0353922Medicaid
MAW22043OtherSRA
MA0353922Medicaid
MA158263OtherHPHC
MAW2600505Medicare PIN