Provider Demographics
NPI:1881666865
Name:ENNIS, JAMES R (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:ENNIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:180 NORTHSTAR
Mailing Address - Street 2:CAPITAL REGION MEDICAL CLINIC
Mailing Address - City:HOLTS SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:65043
Mailing Address - Country:US
Mailing Address - Phone:573-896-5115
Mailing Address - Fax:573-896-4272
Practice Address - Street 1:180 NORTHSTAR
Practice Address - Street 2:
Practice Address - City:HOLTS SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:65043
Practice Address - Country:US
Practice Address - Phone:573-896-5115
Practice Address - Fax:573-896-4272
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6639208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
813149OtherFIRST HEALTH
104257OtherHEALTHLINK
100491OtherBLUE CROSS BLUE SHIELD
7779636OtherCIGNA
MO240009803Medicaid
MO501607808Medicaid
A11722Medicare UPIN
MO001013079Medicare ID - Type Unspecified