Healthcare Provider Details

I. General information

NPI: 1194703017
Provider Name (Legal Business Name): JAMES THOMAS MAIN JR. D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 07/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1854 BROADWAY ST
CAPE GIRARDEAU MO
63701-4553
US

IV. Provider business mailing address

1854 BROADWAY ST
CAPE GIRARDEAU MO
63701-4553
US

V. Phone/Fax

Practice location:
  • Phone: 573-335-1402
  • Fax:
Mailing address:
  • Phone: 573-335-1402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number000500
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: