Provider Demographics
NPI:1104818814
Name:GRIMES, JAMES H (OD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:H
Last Name:GRIMES
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 1:1405 HARRISON AVE NW STE 101
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5327
Mailing Address - Country:US
Mailing Address - Phone:360-357-5548
Mailing Address - Fax:360-786-9797
Practice Address - Street 1:1405 HARRISON AVE NW
Practice Address - Street 2:STE. 101
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5360
Practice Address - Country:US
Practice Address - Phone:360-357-5548
Practice Address - Fax:360-786-9797
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1082152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8028011Medicaid
WA910872462OtherTAX ID #
WA2495208Medicaid
WA2027738Medicaid
WA2027738Medicaid
WA910872462OtherTAX ID #
WA001057900Medicare ID - Type UnspecifiedCLINIC