Provider Demographics
NPI:1780667204
Name:JAMES, DAVID GARY (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GARY
Last Name:JAMES
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 1:17727 W DREAMVIEW CT
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:WI
Mailing Address - Zip Code:53521-9662
Mailing Address - Country:US
Mailing Address - Phone:608-455-1005
Mailing Address - Fax:
Practice Address - Street 1:185 W NETHERWOOD RD
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575-1100
Practice Address - Country:US
Practice Address - Phone:608-835-3579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1673-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38508900Medicaid
WI000047141Medicare ID - Type Unspecified
WVT62304Medicare UPIN