Healthcare Provider Details

I. General information

NPI: 1710993241
Provider Name (Legal Business Name): JAMES B ELLEDGE OD, MBA, FAAO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17134 BULVERDE RD STE 107
SAN ANTONIO TX
78247-2190
US

IV. Provider business mailing address

17134 BULVERDE RD STE 107
SAN ANTONIO TX
78247-2190
US

V. Phone/Fax

Practice location:
  • Phone: 210-267-2686
  • Fax: 210-267-2216
Mailing address:
  • Phone: 210-267-2686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number006941
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT03341
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: