Provider Demographics
NPI:1740349976
Name:INGRAM, GEORGE C JR (OD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:C
Last Name:INGRAM
Suffix:JR
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 1:3919 N MALL AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4906
Mailing Address - Country:US
Mailing Address - Phone:479-527-9325
Mailing Address - Fax:
Practice Address - Street 1:3919 N MALL AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4906
Practice Address - Country:US
Practice Address - Phone:479-527-9325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2097152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ART20159Medicare UPIN
AR48053Medicare ID - Type Unspecified