Provider Demographics
NPI:1194703017
Name:MAIN, JAMES THOMAS JR (DPM)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:THOMAS
Last Name:MAIN
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1854 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-4553
Mailing Address - Country:US
Mailing Address - Phone:573-335-1402
Mailing Address - Fax:
Practice Address - Street 1:1854 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4553
Practice Address - Country:US
Practice Address - Phone:573-335-1402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000500213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO3018793000Medicaid
MO00021152Medicare ID - Type Unspecified
MO3018793000Medicaid