Provider Demographics
NPI:1356367023
Name:MEMMEN, JAMES EDWARD (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:EDWARD
Last Name:MEMMEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4492 CHOCTAW TRL
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-6781
Mailing Address - Country:US
Mailing Address - Phone:920-380-0100
Mailing Address - Fax:920-380-0101
Practice Address - Street 1:1543 PARK PL
Practice Address - Street 2:SUITE 400
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-1970
Practice Address - Country:US
Practice Address - Phone:920-497-0100
Practice Address - Fax:920-497-0101
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29183207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6343730001OtherDMCR / EYEGLASSES
B55018Medicare UPIN
WI31395200Medicare ID - Type Unspecified
WI6343730001OtherDMCR / EYEGLASSES