Provider Demographics
NPI:1285786145
Name:JAMES L DUCKLO OD
Entity type:Organization
Organization Name:JAMES L DUCKLO OD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-731-6230
Mailing Address - Street 1:5252 HICKORY HOLLOW PKWY
Mailing Address - Street 2:SUITE 1133
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-3005
Mailing Address - Country:US
Mailing Address - Phone:615-731-6230
Mailing Address - Fax:615-731-6538
Practice Address - Street 1:5252 HICKORY HOLLOW PKWY
Practice Address - Street 2:SUITE 1133
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-3005
Practice Address - Country:US
Practice Address - Phone:615-731-6230
Practice Address - Fax:615-731-6538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT1233152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNTN1233OtherEYEMED
TN5697119OtherFIRST HEALTH
TN0118062OtherBLUE CROSS BLUE SHIELD
TN0118062OtherBLUE CROSS BLUE SHIELD
TN=========OtherPRINCIPAL
TNTN1233OtherEYEMED
TN5697119OtherFIRST HEALTH
TN=========OtherUNITED HEALTH CARE
TN=========OtherPRINCIPAL