Provider Demographics
NPI:1952301053
Name:HOLCOMB, JOHN L (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:HOLCOMB
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:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:64683-0339
Mailing Address - Country:US
Mailing Address - Phone:660-359-2204
Mailing Address - Fax:660-359-4804
Practice Address - Street 1:1210 OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MO
Practice Address - Zip Code:64683-2559
Practice Address - Country:US
Practice Address - Phone:660-359-2204
Practice Address - Fax:660-359-4804
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2175152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO06429017OtherBLUE CROSS BLUE SHIELD
MOT42505Medicare UPIN
TN0658950001Medicare NSC
MO0001644Medicare PIN