Provider Demographics
NPI:1194718379
Name:ELAM, JIMMY H (OD)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:H
Last Name:ELAM
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:PO BOX 1178
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-7678
Mailing Address - Country:US
Mailing Address - Phone:618-993-5686
Mailing Address - Fax:618-997-6250
Practice Address - Street 1:2511 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2338
Practice Address - Country:US
Practice Address - Phone:573-686-5866
Practice Address - Fax:618-997-6250
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2189152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1194718379Medicaid
MO0814870015Medicare NSC
MO1194718379Medicaid
MO0814870013Medicare NSC
MO0814870017Medicare NSC
MO0814870006Medicare NSC
MO904000004Medicare PIN