Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213EP1101X | Primary Podiatric Medicine | 000500 | MO |
NPI | 1194703017 |
---|---|
Provider Name | James Thomas Main JR. |
First Address | Cape Girardeau, MO 63701-4553 |
Second Address | Cape Girardeau, MO 63701-4553 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/01/2006 |
Last Update Date | 14/07/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3018793000 | (05) | MO |
T42887 | (02) |