Provider Demographics
NPI:1184682635
Name:JAMES, JEFFREY JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JOHN
Last Name:JAMES
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 1:1110 S PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032
Mailing Address - Country:US
Mailing Address - Phone:815-232-1105
Mailing Address - Fax:815-232-3117
Practice Address - Street 1:1110 S PARK BLVD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032
Practice Address - Country:US
Practice Address - Phone:815-232-1105
Practice Address - Fax:815-232-3117
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0002738035152W00000X
IL046008966152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008966Medicaid
IL254060Medicare ID - Type Unspecified
IL046008966Medicaid