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Individual

JIMMY H ELAM

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
OD

Contact information

Practice address
2511 N WESTWOOD BLVD, POPLAR BLUFF, MO 63901-2338
(573) 686-5866
(618) 997-6250
Mailing address
PO BOX 1178, MARION, IL 62959-7678
(618) 993-5686
(618) 997-6250

Taxonomy

Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2189
MO

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
1194718379
MO
Enumeration date
08/24/2005
Last updated
12/13/2011
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