Provider Demographics
NPI:1609803477
Name:EXTINE, JAMES H (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:H
Last Name:EXTINE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 DESIARD ST STE 355
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7363
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-6603
Practice Address - Street 1:2516 BROADMOOR BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2988
Practice Address - Country:US
Practice Address - Phone:318-807-4746
Practice Address - Fax:318-812-6034
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA071493207X00000X
TNDO0000001192207X00000X
LA307337207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2462750Medicaid
TN200037893OtherRAILROAD MEDICARE
TNTN0139OtherAMERICHOICE TENNCARE
TN1170140002OtherPALMETTO GBA
TN373856800OtherOWCP
TN3139316OtherBLUE CROSS BLUE SHIELD TN
TN3304909Medicaid
TN1120944OtherCIGNA