Provider Demographics
NPI:1417019720
Name:HAVENS, JAMES T (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:T
Last Name:HAVENS
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 1:1841 N COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-2382
Mailing Address - Country:US
Mailing Address - Phone:478-452-3593
Mailing Address - Fax:478-453-0016
Practice Address - Street 1:1841 N COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2382
Practice Address - Country:US
Practice Address - Phone:478-452-3593
Practice Address - Fax:478-453-0016
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001328152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41292OtherAVESIS
GA00624247AMedicaid
GA100922OtherAVESIS M'CAID
GA44334OtherSPECTERA
GAU36986Medicare UPIN
GA00624247AMedicaid