Provider Demographics
NPI:1881657617
Name:JOSE, BARRY JAMES (OD)
Entity Type:Individual
Prefix:MR
First Name:BARRY
Middle Name:JAMES
Last Name:JOSE
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 1:1601 AVE D
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501
Mailing Address - Country:US
Mailing Address - Phone:712-323-5213
Mailing Address - Fax:712-323-0722
Practice Address - Street 1:1601 AVE D
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501
Practice Address - Country:US
Practice Address - Phone:712-323-5213
Practice Address - Fax:712-323-0722
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1644152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1140202Medicaid
IA1140202Medicaid
13349Medicare ID - Type Unspecified