MEDICARE: DR. JOHN L HOLCOMB OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2175	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	06429017	OTHER	MO	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1952301053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN L HOLCOMB OD

Provider Business Mailing Address
First Line	:	PO BOX 339
Second Line	:
City	:	TRENTON
State	:	MO
Zip	:	64683-0339
Country	:	US
Telephone Number	:	660-359-2204
Fax Number	:	660-359-4804

Provider Business Practice Location Address
First Line	:	1210 OKLAHOMA AVE
Second Line	:
City	:	TRENTON
State	:	MO
Zip	:	64683-2559
Country	:	US
Telephone Number	:	660-359-2204
Fax Number	:	660-359-4804

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	03/11/2008

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