Provider Demographics
NPI:1336249580
Name:HOLLIS, JIMMY RAY (OD)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:RAY
Last Name:HOLLIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:618 BLOEDEL AVE
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36784-2758
Mailing Address - Country:US
Mailing Address - Phone:334-636-1375
Mailing Address - Fax:334-636-1151
Practice Address - Street 1:34301 HIGHWAY 43
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:AL
Practice Address - Zip Code:36784-3341
Practice Address - Country:US
Practice Address - Phone:334-636-4097
Practice Address - Fax:334-636-1151
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ALS899TA476152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALU75353Medicare UPIN