Provider Demographics
NPI:1982799763
Name:PHILLIPS, JAMES LEE (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LEE
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DO
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 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:4331 S. FREMONT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-820-5000
Practice Address - Fax:417-820-5015
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-7924208000000X
MO2009016967208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1982799763Medicaid
431560263OtherTRICARE WEST
431560263OtherTRICARE WEST