Provider Demographics
NPI:1063499978
Name:VAN WINKLE, JAMES E (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:E
Last Name:VAN WINKLE
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 374
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-0374
Mailing Address - Country:US
Mailing Address - Phone:260-824-3424
Mailing Address - Fax:260-824-9116
Practice Address - Street 1:105 W HARVEST RD
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-9007
Practice Address - Country:US
Practice Address - Phone:260-824-3424
Practice Address - Fax:260-824-9116
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001464152WC0802X, 152W00000X, 152WP0200X, 152WS0006X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN352144351OtherBLUFFTON FAMILY EYE CARE
IN200011590AMedicaid
IN200011590AMedicaid
IN4211170001Medicare NSC
IN182520Medicare ID - Type UnspecifiedBLUFFTON FAMILY EYE CARE
IN182520BMedicare ID - Type UnspecifiedJAMES E VAN WINKLE