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1073243630 NPI number — JESSIE BOYCOTT OD

NPI Number: 1073243630
Health Care Provider/Practitioner: JESSIE BOYCOTT OD

Information about “1073243630” NPI (JESSIE BOYCOTT OD) exists in 1073243630 in HTML format HTML  |  1073243630 in plain Text format TXT  |  1073243630 in PDF (Portable Document Format) PDF  |  1073243630 in an XML format XML  formats.

NPI Number : 1073243630 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1073243630",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "BOYCOTT",
    "FirstName": "JESSIE",
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "OD",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "4142 W DIVISION ST",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "SAINT CLOUD",
    "MailingAddressStateName": "MN",
    "MailingAddressPostalCode": "56301-3706",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": null,
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "3320 EXECUTIVE DR STE 111",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "RALEIGH",
    "PracticeLocationAddressStateName": "NC",
    "PracticeLocationAddressPostalCode": "27609-7445",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "919-876-2427",
    "PracticeLocationAddressFaxNumber": "919-850-9234",
    "EnumerationDate": "06/15/2022",
    "LastUpdateDate": "10/21/2024",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "152W00000X",
          "TaxonomyName": "Optometrist",
          "LicenseNumber": "3796",
          "LicenseNumberStateCode": "MN",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "152W00000X",
          "TaxonomyName": "Optometrist",
          "LicenseNumber": "2691",
          "LicenseNumberStateCode": "NC",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": {
      "HealthcareProviderTaxonomyGroup": {
        "HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
        "HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
      }
    }
  }
}
                
            

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