Provider Demographics
NPI:1710993241
Name:ELLEDGE, JAMES B (OD, MBA, FAAO)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:B
Last Name:ELLEDGE
Suffix:
Gender:M
Credentials:OD, MBA, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17134 BULVERDE RD STE 107
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-2190
Mailing Address - Country:US
Mailing Address - Phone:210-267-2686
Mailing Address - Fax:
Practice Address - Street 1:17134 BULVERDE RD STE 107
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-2190
Practice Address - Country:US
Practice Address - Phone:210-267-2686
Practice Address - Fax:210-267-2216
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006941152W00000X
MOT03341152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist