Provider Demographics
NPI:1043621519
Name:ZIMMER, ZACK
Entity type:Individual
Prefix:
First Name:ZACK
Middle Name:
Last Name:ZIMMER
Suffix:
Gender:M
Credentials:
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 23273
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96823-3273
Mailing Address - Country:US
Mailing Address - Phone:808-295-7311
Mailing Address - Fax:
Practice Address - Street 1:1619 LUSITANA ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-6621
Practice Address - Country:US
Practice Address - Phone:808-295-7311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-18
Last Update Date:2014-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDIO-397156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIW73879484-01OtherSTATE TAX ID
HI45-5485332OtherFEDERAL EIN