Healthcare Provider Details

I. General information

NPI: 1356074090
Provider Name (Legal Business Name): JAMES TREY UPTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2022
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 S NATIONAL AVE
SPRINGFIELD MO
65807-7307
US

IV. Provider business mailing address

3440 S NATIONAL AVE # 2020
SPRINGFIELD MO
65807-7307
US

V. Phone/Fax

Practice location:
  • Phone: 417-886-5444
  • Fax: 417-725-0502
Mailing address:
  • Phone: 417-725-0500
  • Fax: 417-725-0502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2856
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2024017966
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: