Provider Demographics
NPI:1073597290
Name:ABBOTT, JAMES L (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:ABBOTT
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 1:1919 E MCKELLIPS RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-2844
Mailing Address - Country:US
Mailing Address - Phone:480-844-2286
Mailing Address - Fax:480-610-6641
Practice Address - Street 1:1919 E MCKELLIPS RD
Practice Address - Street 2:SUITE 103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-2844
Practice Address - Country:US
Practice Address - Phone:480-844-2286
Practice Address - Fax:480-610-6641
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ338152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZT41330Medicare UPIN
AZZ104182Medicare ID - Type Unspecified