Provider Demographics
NPI:1114105731
Name:BOB HAM EYEWEAR INC
Entity Type:Organization
Organization Name:BOB HAM EYEWEAR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:HAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:904-268-5949
Mailing Address - Street 1:9965 SAN JOSE BLVD STE 24
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-5866
Mailing Address - Country:US
Mailing Address - Phone:904-268-5949
Mailing Address - Fax:904-268-6867
Practice Address - Street 1:9965 SAN JOSE BLVD STE 24
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-5866
Practice Address - Country:US
Practice Address - Phone:904-268-5949
Practice Address - Fax:904-268-5949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOE263332H00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0684690001Medicare NSC