Healthcare Provider Details

I. General information

NPI: 1326117136
Provider Name (Legal Business Name): JAMES MILTON OTIS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 BROWNS MILL ROAD
JOHNSON CITY TN
37604
US

IV. Provider business mailing address

3111 BROWNS MILL ROAD
JOHNSON CITY TN
37604
US

V. Phone/Fax

Practice location:
  • Phone: 423-283-0969
  • Fax: 423-283-7002
Mailing address:
  • Phone: 423-283-0969
  • Fax: 423-283-7002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODT581
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: