Provider Demographics
NPI:1124043724
Name:FOX, JAMAL JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMAL
Middle Name:JAMES
Last Name:FOX
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 1:2037 DORSETT VLG
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-2207
Mailing Address - Country:US
Mailing Address - Phone:314-205-9797
Mailing Address - Fax:314-838-3311
Practice Address - Street 1:3819 VAILE AVE
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63034-2227
Practice Address - Country:US
Practice Address - Phone:314-838-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1859152W00000X
MO2006001515152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1124043724Medicaid
MO311309900Medicaid
MO1124043724Medicaid
MOMA6568002Medicare PIN
MO311309900Medicaid
MO074730016Medicare PIN
MO067820012Medicare PIN