Provider Demographics
NPI:1225022635
Name:PACE, JAMES R (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:PACE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1039 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-2906
Mailing Address - Country:US
Mailing Address - Phone:316-262-8476
Mailing Address - Fax:316-262-8477
Practice Address - Street 1:1039 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-2906
Practice Address - Country:US
Practice Address - Phone:316-262-8476
Practice Address - Fax:316-262-8477
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS972-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS665030OtherFIRST GUARD
KS4083937OtherAETNA
KS1241OtherPREFERRED HEALTH SYSTEMS
KS410044812OtherRAILROAD MEDICARE
KS100090590BMedicaid
KS650799OtherBLUE CROSS BLUE SHIELD
KS650799Medicare ID - Type Unspecified
KS1241OtherPREFERRED HEALTH SYSTEMS
KS410044812OtherRAILROAD MEDICARE
KST43720Medicare UPIN
KS100090590BMedicaid