Provider Demographics
NPI:1952465528
Name:HIGINBOTHAM, JOHN PATRICK (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PATRICK
Last Name:HIGINBOTHAM
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 1:467 W PATRICK ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-4805
Mailing Address - Country:US
Mailing Address - Phone:301-663-8858
Mailing Address - Fax:301-663-8871
Practice Address - Street 1:467 W PATRICK ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4805
Practice Address - Country:US
Practice Address - Phone:301-663-8858
Practice Address - Fax:301-663-8871
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2008-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1174152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0797360001Medicare NSC
MDU36333Medicare UPIN
MDX385Medicare ID - Type UnspecifiedOPTOMETRY