Provider Demographics
NPI:1891756011
Name:INGRAM, JAMES R (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:INGRAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 CANYON RD STE C1
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-8493
Mailing Address - Country:US
Mailing Address - Phone:928-444-1491
Mailing Address - Fax:928-444-1330
Practice Address - Street 1:2500 CANYON RD STE C1
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8493
Practice Address - Country:US
Practice Address - Phone:928-444-1491
Practice Address - Fax:928-444-1330
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ010823207X00000X
TXM9369207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX199871802Medicaid
TXTXB113487Medicare PIN