Basic Information
Provider Information | |||||||||
NPI: | 1245288422 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OUELLETTE | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3170 KETTERING BLVD BLDG B3 | ||||||||
Address2: |   | ||||||||
City: | MORAINE | ||||||||
State: | OH | ||||||||
PostalCode: | 454391924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9379913191 | ||||||||
FaxNumber: | 9372239811 | ||||||||
Practice Location | |||||||||
Address1: | 2300 MIAMI VALLEY DR | ||||||||
Address2: | SUITE 350 | ||||||||
City: | CENTERVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 45459 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9374242469 | ||||||||
FaxNumber: | 9374242479 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 08/01/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 34007386 | OH | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 2086X0206X | 340073869 | OH | Y |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
ID | Type | State | Issuer | Description | 2192550 | 05 | OH |   | MEDICAID |