Provider Demographics
NPI:1205459377
Name:COMBS, ELICK JAN III (OD)
Entity type:Individual
Prefix:DR
First Name:ELICK
Middle Name:JAN
Last Name:COMBS
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1124 E WEISGARBER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2686
Mailing Address - Country:US
Mailing Address - Phone:865-584-0905
Mailing Address - Fax:865-584-3892
Practice Address - Street 1:221 E EMORY RD STE 103
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-4061
Practice Address - Country:US
Practice Address - Phone:865-584-0905
Practice Address - Fax:865-584-3892
Is Sole Proprietor?:No
Enumeration Date:2020-05-25
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3594152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ057803Medicaid