Healthcare Provider Details

I. General information

NPI: 1326795865
Provider Name (Legal Business Name): JAMES THOMAS SELLERS V
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 ILLINOIS AVE
FORT LEONARD WOOD MO
65473-9098
US

IV. Provider business mailing address

4234 ILLINOIS AVE
FORT LEONARD WOOD MO
65473-9098
US

V. Phone/Fax

Practice location:
  • Phone: 573-596-0417
  • Fax:
Mailing address:
  • Phone: 573-596-0417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35969
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: