Provider Demographics
NPI:1073509675
Name:HALL, JAMES R (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:HALL
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 1:11 W LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-1417
Mailing Address - Country:US
Mailing Address - Phone:610-642-2151
Mailing Address - Fax:610-642-2190
Practice Address - Street 1:11 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-1417
Practice Address - Country:US
Practice Address - Phone:610-642-2151
Practice Address - Fax:610-642-2190
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2011-11-17
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
PAOEG001134152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2031815000OtherKEYSTONE HEALTHPLN EAST
PAT30566Medicare UPIN
PA462583Medicare PIN
PA0640690001Medicare NSC