Provider Demographics
NPI:1265484042
Name:FORNES , OD, JAMES CHARLES (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:CHARLES
Last Name:FORNES , OD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301 BAY PARK SQ
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5104
Mailing Address - Country:US
Mailing Address - Phone:920-499-3511
Mailing Address - Fax:920-499-9215
Practice Address - Street 1:301 BAY PARK SQ
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5104
Practice Address - Country:US
Practice Address - Phone:920-499-3511
Practice Address - Fax:920-499-9215
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI1465152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38504800Medicaid
WI38504800Medicaid