Provider Demographics
NPI:1992747745
Name:JAMES, MARK E (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:JAMES
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 1:822 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2266
Mailing Address - Country:US
Mailing Address - Phone:920-887-3791
Mailing Address - Fax:
Practice Address - Street 1:822 PARK AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2266
Practice Address - Country:US
Practice Address - Phone:920-887-3791
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2181152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38422300Medicaid
WIU31134Medicare UPIN