Provider Demographics
NPI:1902864085
Name:TICKNER, JAMES M (OD, MA)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:M
Last Name:TICKNER
Suffix:
Gender:M
Credentials:OD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 391
Mailing Address - Street 2:
Mailing Address - City:LAKE ARIEL
Mailing Address - State:PA
Mailing Address - Zip Code:18436-0391
Mailing Address - Country:US
Mailing Address - Phone:570-251-9657
Mailing Address - Fax:
Practice Address - Street 1:777 OLD WILLOW AVE
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-4217
Practice Address - Country:US
Practice Address - Phone:570-251-9657
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001159152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA82187OtherGEISINGER PIN NUMBER
PA1510066OtherHIGHMARK BLUESHIELD PIN
PA817310OtherFIRST PRIORITY PIN
PAU96140Medicare UPIN
PA1510066OtherHIGHMARK BLUESHIELD PIN