Provider Demographics
NPI:1760529408
Name:MOLDE, JAMES A (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:MOLDE
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 1:506 BELTRAMI AVE NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3010
Mailing Address - Country:US
Mailing Address - Phone:218-751-2020
Mailing Address - Fax:218-759-9228
Practice Address - Street 1:506 BELTRAMI AVE NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3010
Practice Address - Country:US
Practice Address - Phone:218-751-2020
Practice Address - Fax:218-759-9228
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1728152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
1018420OtherPREFERREDONE
MN48B51MOOtherMN BCBS
HP29311OtherHEALTHPARTNERS
MN794523000Medicaid
ND28771OtherND BCBS
ND28771OtherND BCBS
1018420OtherPREFERREDONE
HP29311OtherHEALTHPARTNERS